Provider Demographics
NPI:1538111695
Name:JACOBS, JACQUELYN (DPM)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2248 MURRELL ROAD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-2100
Mailing Address - Country:US
Mailing Address - Phone:800-292-3008
Mailing Address - Fax:330-629-9181
Practice Address - Street 1:2248 MURRELL ROAD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2100
Practice Address - Country:US
Practice Address - Phone:800-292-3008
Practice Address - Fax:330-629-9181
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000903213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010191998Medicaid
VA181784OtherANTHEM BC BS
VA010191998Medicaid
VA00W210P01Medicare ID - Type Unspecified
VAU43063Medicare UPIN
VAP00276625Medicare PIN
5739620001Medicare NSC