Provider Demographics
NPI:1316995038
Name:JACOBS, HENRY JR (CSA)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:JR
Last Name:JACOBS
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3913 MORTON DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-1287
Mailing Address - Country:US
Mailing Address - Phone:804-239-8208
Mailing Address - Fax:
Practice Address - Street 1:3913 MORTON DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-1287
Practice Address - Country:US
Practice Address - Phone:804-239-8208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3123363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical