MEDICARE: JERMAINE JACOBS

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	172A00000X	Driver

General Provider Information

NPI Number	:	1063958874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERMAINE JACOBS

Provider Business Mailing Address
First Line	:	2918 11TH ST
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-4801
Country	:	US
Telephone Number	:	409-543-1799
Fax Number	:

Provider Business Practice Location Address
First Line	:	2918 11TH ST
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-4801
Country	:	US
Telephone Number	:	409-543-1799
Fax Number	:

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

Provider Enumeration Date	:	01/18/2017
Last Update Date	:	01/18/2017

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Directions to “ JERMAINE JACOBS ” Practice Location

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