Provider Demographics
NPI:1528332871
Name:JACOB, BROOKE L (RD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:L
Last Name:JACOB
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 30170
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-7170
Mailing Address - Country:US
Mailing Address - Phone:302-623-7113
Mailing Address - Fax:302-623-7374
Practice Address - Street 1:4735 OGLETOWN STANTON ROAD
Practice Address - Street 2:SUITE 3201
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-623-4323
Practice Address - Fax:302-623-4315
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEDN-0000379133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered