Provider Demographics
NPI:1770210395
Name:JACOB, MARIAH
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:JACOB
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 1:24 S 1000 E
Mailing Address - Street 2:
Mailing Address - City:CELESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:47521-9659
Mailing Address - Country:US
Mailing Address - Phone:812-827-3027
Mailing Address - Fax:
Practice Address - Street 1:3150 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1858
Practice Address - Country:US
Practice Address - Phone:812-504-2264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant