Provider Demographics
NPI:1386485167
Name:JACOBS, AMANDA MARIE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
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 1:41 KINGWOOD PL
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1733
Mailing Address - Country:US
Mailing Address - Phone:860-938-5602
Mailing Address - Fax:
Practice Address - Street 1:1615 STANLEY ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06050-2439
Practice Address - Country:US
Practice Address - Phone:860-832-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer