MEDICARE: DOMINIQUE 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1073938130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE JACOBS

Provider Business Mailing Address
First Line	:	200 SAINT CHARLES PL
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-3913
Country	:	US
Telephone Number	:	912-439-0207
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 SAINT CHARLES PL
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-3913
Country	:	US
Telephone Number	:	912-439-0207
Fax Number	:

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

Provider Enumeration Date	:	02/26/2014
Last Update Date	:	02/26/2014

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