Provider Demographics
NPI:1215915111
Name:JACOBS, BRIAN S (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:JACOBS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1020 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-1729
Practice Address - Country:US
Practice Address - Phone:570-398-1991
Practice Address - Fax:570-398-4607
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014838207Q00000X, 207XX0005X
MN47004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN670998200Medicaid
PA102381212Medicaid
PA102381212Medicaid
PAJA166651Medicare Oscar/Certification
MNP00166859Medicare ID - Type UnspecifiedRAILROAD
MN670998200Medicaid