Basic Information
| Provider Information | |||||||||
| NPI: | 1790882447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBETZ | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 E BROAD ST | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180186332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109546048 | ||||||||
| FaxNumber: | 6109543189 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109543060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD066462L | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0017912780003 | 05 | PA | MEDICAID |