Provider Demographics
NPI:1396056701
Name:JACOBS, MARILYN FRANCES
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:FRANCES
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 1:26276 KING EDWARDS DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4157
Mailing Address - Country:US
Mailing Address - Phone:909-796-0104
Mailing Address - Fax:
Practice Address - Street 1:1133 N MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2554
Practice Address - Country:US
Practice Address - Phone:909-825-6371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist