Basic Information
Provider Information | |||||||||
NPI: | 1831118611 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBS | ||||||||
FirstName: | MARIANNE | ||||||||
MiddleName: | BERNADETTE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370275005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153455400 | ||||||||
FaxNumber: | 6153455405 | ||||||||
Practice Location | |||||||||
Address1: | 3109 SILKWOOD LN | ||||||||
Address2: |   | ||||||||
City: | PORT CHARLOTTE | ||||||||
State: | FL | ||||||||
PostalCode: | 339535686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153455400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 09/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 31615 | CO | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P2900X | 31615 | CO | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 2084S0012X | 31615 | CO | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 2084N0400X | OS5346 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 01316157 | 05 | CO |   | MEDICAID | 84132889816 | 01 |   | SECURE HORIZONS | OTHER | 50813 | 01 | CT | STATE LICENSE | OTHER | 57444Y | 01 | FL | MEDICARE PTAN | OTHER | 841328898011 | 01 |   | ROCKY MOUNTAIN HEALTH PLA | OTHER | P01290076 | 01 | FL | RAILROAD MEDICARE | OTHER |