Provider Demographics
NPI:1801880414
Name:JACOBS, MARY E (ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:JACOBS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1715 W OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1120
Mailing Address - Country:US
Mailing Address - Phone:765-677-1675
Mailing Address - Fax:765-677-1676
Practice Address - Street 1:4201 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4974
Practice Address - Country:US
Practice Address - Phone:765-677-1675
Practice Address - Fax:765-677-1676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000359A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer