Healthcare Provider Details

I. General information

NPI: 1144588872
Provider Name (Legal Business Name): VICTORIA MARIE GROUNDS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA M JACOBS

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MAIN ST
GUN BARREL CITY TX
75156-5312
US

IV. Provider business mailing address

PO BOX 1610
ATHENS TX
75751-1610
US

V. Phone/Fax

Practice location:
  • Phone: 903-887-1011
  • Fax: 903-603-9441
Mailing address:
  • Phone: 903-603-7067
  • Fax: 903-603-7595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09110
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: