Provider Demographics
NPI:1669058756
Name:JACOBS, KAYLA DANIELLE (RPH)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:DANIELLE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 OLD CAPITAL PLZ NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2081
Mailing Address - Country:US
Mailing Address - Phone:812-738-7191
Mailing Address - Fax:812-738-0642
Practice Address - Street 1:255 OLD CAPITAL PLZ NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2081
Practice Address - Country:US
Practice Address - Phone:812-738-7191
Practice Address - Fax:812-738-0642
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016807183500000X
IN26025144A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN311186877OtherFEDERAL TAX ID
IN1659474385Medicaid