Provider Demographics
NPI:1487702569
Name:JACOBS, LAURIE BETH (RDH)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:BETH
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6834 ARIEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2634
Mailing Address - Country:US
Mailing Address - Phone:904-745-3220
Mailing Address - Fax:
Practice Address - Street 1:8627 CINNAMON CREEK DR BLDG 401
Practice Address - Street 2:THE OMO GROUP
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240
Practice Address - Country:US
Practice Address - Phone:210-691-5116
Practice Address - Fax:210-691-5122
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH15572124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist