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General NPI Number Information
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NPI Number | 1093989006
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Entity Type | Organization
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Legal Business Name | JON R JACOBS
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 9213 UNIVERSITY BLVD STE D
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9145
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Country | US
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Telephone | 843-797-6564
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Fax | 843-572-9165
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Provider Business Mailing Address
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Address Line | 9213 UNIVERSITY BLVD STE D
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City | NORTH CHARLESTON
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State | SC
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Zip | 29406-9145
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Country | US
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Telephone | 843-797-6564
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Fax | 843-572-9165
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. SHANNON LEIGH SMITH
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Credential | RN
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Telephone | 843-797-6564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 199702336
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License Number State | SC
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