Provider Demographics
NPI:1154555761
Name:JACOBS, TRAVIS LEE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:354 LIBERTY WAY APT 3B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-8528
Mailing Address - Country:US
Mailing Address - Phone:315-778-8749
Mailing Address - Fax:
Practice Address - Street 1:1523 VOORHIES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3912
Practice Address - Country:US
Practice Address - Phone:718-808-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2022-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1086052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant