MEDICARE: DR. KENNETH ALLEN JACOBS PHARMD

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	183500000X	Pharmacist	5302024203	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5302024203	OTHER	MI	PHARMACY LICENSE NUMBER

General Provider Information

NPI Number	:	1225252810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ALLEN JACOBS PHARMD

Provider Business Mailing Address
First Line	:	7517 DANBURY DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3564
Country	:	US
Telephone Number	:	248-895-0216
Fax Number	:

Provider Business Practice Location Address
First Line	:	18500 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-2319
Country	:	US
Telephone Number	:	313-272-5256
Fax Number	:	313-272-9780

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

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	10/02/2013

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