Provider Demographics
NPI:1881069599
Name:JACOB, ROSE MARY I
Entity type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:MARY
Last Name:JACOB
Suffix:I
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ROSE
Other - Middle Name:MARY
Other - Last Name:JACOB
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1224 E LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85721-0095
Mailing Address - Country:US
Mailing Address - Phone:520-626-2792
Mailing Address - Fax:520-621-5644
Practice Address - Street 1:1224 E LOWELL ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0095
Practice Address - Country:US
Practice Address - Phone:520-626-2792
Practice Address - Fax:520-621-5644
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN036304163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse