Provider Demographics
NPI:1154960649
Name:JACOBS, REBECCA R
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:R
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 1:4062 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9543
Mailing Address - Country:US
Mailing Address - Phone:269-779-9003
Mailing Address - Fax:
Practice Address - Street 1:4062 MEADOW LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9543
Practice Address - Country:US
Practice Address - Phone:269-779-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health