Provider Demographics
NPI:1255444238
Name:JACOBS, RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1103
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-1103
Mailing Address - Country:US
Mailing Address - Phone:850-485-7012
Mailing Address - Fax:
Practice Address - Street 1:215 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4465
Practice Address - Country:US
Practice Address - Phone:850-916-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9180111N00000X
AL2160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor