Provider Demographics
NPI:1578186722
Name:JACOBS, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
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 1:1265 FAIRWAY TER
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-9619
Mailing Address - Country:US
Mailing Address - Phone:252-287-8717
Mailing Address - Fax:
Practice Address - Street 1:146 GLOVERS CROSS RD
Practice Address - Street 2:
Practice Address - City:COLERAIN
Practice Address - State:NC
Practice Address - Zip Code:27924-9444
Practice Address - Country:US
Practice Address - Phone:252-287-8718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider