Provider Demographics
NPI:1952086639
Name:JACOBS, SCOTT DOMINICK JR
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DOMINICK
Last Name:JACOBS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 E MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2843
Mailing Address - Country:US
Mailing Address - Phone:985-507-0273
Mailing Address - Fax:
Practice Address - Street 1:200 HENRY CLAY AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-5720
Practice Address - Country:US
Practice Address - Phone:985-507-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3371482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer