MEDICARE: DR. BRIAN BERNARD JACOBUS DDS, MS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN10314	FL

General Provider Information

NPI Number	:	1134143340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN BERNARD JACOBUS DDS, MS, PA

Provider Business Mailing Address
First Line	:	1100 SW SAINT LUCIE WEST BLVD STE 207
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-1735
Country	:	US
Telephone Number	:	772-340-0023
Fax Number	:	772-340-0840

Provider Business Practice Location Address
First Line	:	1100 SW SAINT LUCIE WEST BLVD STE 207
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-1735
Country	:	US
Telephone Number	:	772-340-0023
Fax Number	:	772-340-0840

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	12/19/2007

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