Provider Demographics
NPI:1174541734
Name:JACOBS, STANLEY R (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S 9TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4408
Mailing Address - Country:US
Mailing Address - Phone:215-955-1200
Mailing Address - Fax:215-923-6808
Practice Address - Street 1:25 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4408
Practice Address - Country:US
Practice Address - Phone:215-955-1200
Practice Address - Fax:215-923-3729
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014283-E208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000759712Medicaid
NJ2115603Medicaid
PA000759712Medicaid