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General NPI Number Information
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NPI Number | 1134082266
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Entity Type | Individual
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Provider Name | MARY JACUBEC
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Gender |
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Dates
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Enumeration Date | 12/05/2025
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Last Update Date | 12/05/2025
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Provider Practice Location Address
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Address Line | 17222 HOSPITAL BLVD STE 346
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City | BROOKSVILLE
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State | FL
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Zip | 34601-8925
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Country | US
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Telephone | 352-796-3334
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Fax |
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Provider Business Mailing Address
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Address Line | 12561 92ND WAY
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City | LARGO
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State | FL
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Zip | 33773-2534
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | PA9121019
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License Number State | FL
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