Basic Information
Provider Information | |||||||||
NPI: | 1295724458 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | SUE | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACOBS | ||||||||
OtherFirstName: | SUSAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 33255 9TH ST | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 945872137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5104715880 | ||||||||
FaxNumber: | 5104719051 | ||||||||
Practice Location | |||||||||
Address1: | 33255 9TH ST | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 945872137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5104715880 | ||||||||
FaxNumber: | 5104719051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2005 | ||||||||
LastUpdateDate: | 10/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | NMW912 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
No ID Information.