Provider Demographics
NPI:1194150896
Name:JACOBS, MADEIA H
Entity type:Individual
Prefix:
First Name:MADEIA
Middle Name:H
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 1:3313 N MARSTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1318
Mailing Address - Country:US
Mailing Address - Phone:610-690-2500
Mailing Address - Fax:
Practice Address - Street 1:225 N PRESIDENTIAL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1258
Practice Address - Country:US
Practice Address - Phone:215-907-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN293559L163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1194150896Medicaid