Provider Demographics
NPI:1811973894
Name:JACOBS, MARY AMANDA (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:200 SCENERY DR.
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-5602
Practice Address - Country:US
Practice Address - Phone:814-231-4560
Practice Address - Fax:814-231-6246
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46763207N00000X
PAMD437386207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
PA102337081Medicaid
MN699485700Medicaid
MNP00333407OtherRAILROAD MEDICARE
WI35163500Medicaid
IAENROLLEDMedicaid
MN070000684Medicare PIN