Provider Demographics
NPI:1871390898
Name:JACOBS, MELLADA (APRN)
Entity type:Individual
Prefix:
First Name:MELLADA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8355
Mailing Address - Country:US
Mailing Address - Phone:803-239-7480
Mailing Address - Fax:
Practice Address - Street 1:2010 W DEKALB ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2058
Practice Address - Country:US
Practice Address - Phone:803-272-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-26
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily