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General NPI Number Information
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NPI Number | 1568679876
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Entity Type | Individual
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Provider Name | DERIC L JACOBS DC
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Gender | Male
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 01/14/2010
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Provider Practice Location Address
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Address Line | 4536 S. CLYDE MORRIS BLVD. SUITE 3
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City | PORT ORANGE
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State | FL
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Zip | 32129-4017
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Country | US
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Telephone | 386-562-4099
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Fax |
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Provider Business Mailing Address
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Address Line | 3625 SCOTT ST
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City | PORT ORANGE
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State | FL
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Zip | 32129-4225
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Country | US
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Telephone | 386-562-4099
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH8698
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License Number State | FL
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