Provider Demographics
NPI:1366789091
Name:JACOB, MELANIE A (RD CSSD)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:A
Last Name:JACOB
Suffix:
Gender:F
Credentials:RD CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E BIG BEAVER RD STE B
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1435
Mailing Address - Country:US
Mailing Address - Phone:248-244-2213
Mailing Address - Fax:248-275-5558
Practice Address - Street 1:700 E BIG BEAVER RD STE B
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1435
Practice Address - Country:US
Practice Address - Phone:248-244-2213
Practice Address - Fax:248-275-5558
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered