Provider Demographics
NPI:1043882731
Name:JACOB, MARTHA ANN
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
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 1:286 SOUTHERN RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-6764
Mailing Address - Country:US
Mailing Address - Phone:304-783-4481
Mailing Address - Fax:
Practice Address - Street 1:286 SOUTHERN RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-6764
Practice Address - Country:US
Practice Address - Phone:304-783-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant