Provider Demographics
NPI:1457518755
Name:JAKUBEC, PATRICIA LOUISE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LOUISE
Last Name:JAKUBEC
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 1:13226 MOBY DICK DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-2891
Mailing Address - Country:US
Mailing Address - Phone:904-614-2709
Mailing Address - Fax:
Practice Address - Street 1:13226 MOBY DICK DR W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2891
Practice Address - Country:US
Practice Address - Phone:904-614-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9674133V00000X
FLDH17696124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDH17696OtherREGISTERED DENTAL HYGIENIST