MEDICARE: DERIC L JACOBS DC

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	111N00000X	Chiropractor	CH8698	FL

General Provider Information

NPI Number	:	1568679876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERIC L JACOBS DC

Provider Business Mailing Address
First Line	:	3625 SCOTT ST
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4225
Country	:	US
Telephone Number	:	386-562-4099
Fax Number	:

Provider Business Practice Location Address
First Line	:	4536 S. CLYDE MORRIS BLVD.
Second Line	:	SUITE 3
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-4017
Country	:	US
Telephone Number	:	386-562-4099
Fax Number	:

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

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	01/14/2010

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