Provider Demographics
NPI:1487991246
Name:JACOB, SUSAN
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:JACOB
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 1:5473 NW SAINT JAMES DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3444
Mailing Address - Country:US
Mailing Address - Phone:772-878-1526
Mailing Address - Fax:772-878-5446
Practice Address - Street 1:5473 NW SAINT JAMES DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3444
Practice Address - Country:US
Practice Address - Phone:772-878-1526
Practice Address - Fax:772-878-5446
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS47566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist