1528332871 NPI number — BROOKE L JACOB RD

Table of content: BROOKE L JACOB RD (NPI 1528332871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528332871 NPI number — BROOKE L JACOB RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOB
Provider First Name:
BROOKE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528332871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 30170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19805-7170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-623-7113
Provider Business Mailing Address Fax Number:
302-623-7374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4735 OGLETOWN STANTON ROAD
Provider Second Line Business Practice Location Address:
SUITE 3201
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-623-4323
Provider Business Practice Location Address Fax Number:
302-623-4315
Provider Enumeration Date:
03/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  DN-0000379 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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