MEDICARE: MRS. SUSAN JACOB

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	PS47566	FL

General Provider Information

NPI Number	:	1487991246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN JACOB

Provider Business Mailing Address
First Line	:	5473 NW SAINT JAMES DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-3444
Country	:	US
Telephone Number	:	772-878-1526
Fax Number	:	772-878-5446

Provider Business Practice Location Address
First Line	:	5473 NW SAINT JAMES DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-3444
Country	:	US
Telephone Number	:	772-878-1526
Fax Number	:	772-878-5446

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

Provider Enumeration Date	:	01/12/2013
Last Update Date	:	01/12/2013

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