Provider Demographics
NPI:1487122248
Name:JACOBS, LAKENYA
Entity type:Individual
Prefix:
First Name:LAKENYA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 COMMERCE RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-4732
Mailing Address - Country:US
Mailing Address - Phone:321-626-0930
Mailing Address - Fax:
Practice Address - Street 1:937 COMMERCE RD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-4732
Practice Address - Country:US
Practice Address - Phone:321-626-0930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100108400Medicaid