Provider Demographics
NPI:1306811575
Name:JACOBS, MADELEINE (MD)
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:PENROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81240-9683
Mailing Address - Country:US
Mailing Address - Phone:719-372-6555
Mailing Address - Fax:719-372-6559
Practice Address - Street 1:91 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:PENROSE
Practice Address - State:CO
Practice Address - Zip Code:81240-9683
Practice Address - Country:US
Practice Address - Phone:719-372-6555
Practice Address - Fax:719-372-6559
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01271006Medicaid
CO01271006Medicaid
45571Medicare ID - Type Unspecified