Provider Demographics
NPI:1699730655
Name:JACOBS, MADELYN J (MD)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:J
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4950 NORTON HEALTHCARE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2845
Practice Address - Country:US
Practice Address - Phone:502-394-6200
Practice Address - Fax:502-394-6210
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000052154NOtherHUMANA - CMA
KY50007053OtherPASSPORT - CMA
KY2448228000OtherPASSPORT ADVTG - CMA
KY64197742Medicaid
KY017347OtherSIHO - CMA
KY1198337OtherCHA - CMA
KYP00176889OtherRAILROAD MEDICARE
KY000000350622OtherANTHEM - CMA
KY6980512-006OtherCIGNA - CMA
KY50007053OtherPASSPORT - CMA
KY000052154NOtherHUMANA - CMA