Provider Demographics
NPI:1912255613
Name:JACOBS, GORDON WILLIAM
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WILLIAM
Last Name:JACOBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 E LANSING DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7755
Mailing Address - Country:US
Mailing Address - Phone:517-332-1616
Mailing Address - Fax:517-332-1538
Practice Address - Street 1:202 1/2 BRIDGE ST
Practice Address - Street 2:APT 6
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837
Practice Address - Country:US
Practice Address - Phone:989-745-3552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide