Provider Demographics
NPI:1801613823
Name:JACOBS, MADISON (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6743 W 135TH ST APT 409
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-8035
Mailing Address - Country:US
Mailing Address - Phone:515-577-1868
Mailing Address - Fax:
Practice Address - Street 1:6743 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-8060
Practice Address - Country:US
Practice Address - Phone:515-577-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-21
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered