MEDICARE: MARINEL JACOBS PT

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	225100000X	Physical Therapist	2305206590	VA

General Provider Information

NPI Number	:	1740594308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINEL JACOBS PT

Provider Business Mailing Address
First Line	:	14605 POTOMAC BRANCH DR
Second Line	:	SUITE #300
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3336
Country	:	US
Telephone Number	:	703-490-1330
Fax Number	:	703-878-8735

Provider Business Practice Location Address
First Line	:	14605 POTOMAC BRANCH DR
Second Line	:	SUITE #300
City	:	WOODBRIDGE
State	:	VA
Zip	:	22191-3336
Country	:	US
Telephone Number	:	703-490-1330
Fax Number	:	703-878-8735

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	07/31/2013

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