Provider Demographics
NPI:1760672364
Name:JACOBS, ALFONZO L (SFIDC)
Entity type:Individual
Prefix:MR
First Name:ALFONZO
Middle Name:L
Last Name:JACOBS
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:707 MOSS ST
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-0932
Mailing Address - Country:US
Mailing Address - Phone:228-246-9613
Mailing Address - Fax:
Practice Address - Street 1:707 MOSS ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-0932
Practice Address - Country:US
Practice Address - Phone:228-246-9613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman