Provider Demographics
NPI:1700489523
Name:JACOBS, LAURA MEGAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MEGAN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-1944
Mailing Address - Country:US
Mailing Address - Phone:706-625-5452
Mailing Address - Fax:706-629-3058
Practice Address - Street 1:402 N WALL ST
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-1944
Practice Address - Country:US
Practice Address - Phone:706-625-5452
Practice Address - Fax:706-629-3058
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist