Provider Demographics
NPI:1538806179
Name:JACOBS, CHARLENE
Entity type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 KINLER ST
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-4533
Mailing Address - Country:US
Mailing Address - Phone:504-416-1840
Mailing Address - Fax:
Practice Address - Street 1:320 WILLIAMS BLVD
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-7630
Practice Address - Country:US
Practice Address - Phone:504-416-1840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X, 332B00000X
LA4415901191744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management