Provider Demographics
NPI:1740302322
Name:JACOBS FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:JACOBS FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-786-3030
Mailing Address - Street 1:102 E FOURTH ST
Mailing Address - Street 2:PO BOX 1018
Mailing Address - City:DEQUINCY
Mailing Address - State:LA
Mailing Address - Zip Code:70633-3502
Mailing Address - Country:US
Mailing Address - Phone:337-786-3030
Mailing Address - Fax:337-786-6066
Practice Address - Street 1:102 E FOURTH ST
Practice Address - Street 2:
Practice Address - City:DEQUINCY
Practice Address - State:LA
Practice Address - Zip Code:70633-3502
Practice Address - Country:US
Practice Address - Phone:337-786-3030
Practice Address - Fax:337-786-5066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08646R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1921718Medicaid
LA1921718Medicaid
LA5N642Medicare ID - Type Unspecified