MEDICARE: JOHN J. 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	332BC3200X	Customized Equipment (DME)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PFEET FIRST	OTHER	NY	MONROE PLAN
2	PFEET FIRST	OTHER	NY	BLUE CHOICE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	FFI190146	OTHER	NY	BLUE CROSS BLUE SHIELD
5	104442-GD	OTHER	NY	PREFERRED CARE

General Provider Information

NPI Number	:	1639226145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN J. JACOBS

Provider Business Mailing Address
First Line	:	1900 CLINTON AVE S
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5621
Country	:	US
Telephone Number	:	585-442-4990
Fax Number	:	585-442-7169

Provider Business Practice Location Address
First Line	:	1900 CLINTON AVE S
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-5621
Country	:	US
Telephone Number	:	585-442-4990
Fax Number	:	585-442-7169

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN J. JACOBS
Credential	:	PH.D., C-PED
Telephone Number	:	585-442-4990

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	06/23/2008

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