Provider Demographics
NPI:1134950520
Name:JACOBS, MATTIE GRACE
Entity type:Individual
Prefix:
First Name:MATTIE
Middle Name:GRACE
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 1:7689 WESTLAKE RD
Mailing Address - Street 2:
Mailing Address - City:STERLINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:71280-3231
Mailing Address - Country:US
Mailing Address - Phone:318-381-7320
Mailing Address - Fax:
Practice Address - Street 1:323 W WALNUT AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4521
Practice Address - Country:US
Practice Address - Phone:318-283-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program