Provider Demographics
NPI:1619708385
Name:JACOBS, ANGELA (HIS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5927
Mailing Address - Country:US
Mailing Address - Phone:207-893-2930
Mailing Address - Fax:207-893-2939
Practice Address - Street 1:2 PLAZA DR
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5927
Practice Address - Country:US
Practice Address - Phone:207-893-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDL470237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty