Provider Demographics
NPI:1952523698
Name:JACOBS, MARILYN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:ELIZABETH
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 1:105 S BROADWAY ST
Mailing Address - Street 2:SUITE 730
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-4227
Mailing Address - Country:US
Mailing Address - Phone:316-393-9933
Mailing Address - Fax:
Practice Address - Street 1:105 S BROADWAY ST
Practice Address - Street 2:SUITE 730
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-4227
Practice Address - Country:US
Practice Address - Phone:316-393-9933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32354207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200426290AMedicaid
KS200426290AMedicaid