Provider Demographics
NPI:1053560961
Name:JACOBY, SHERRIE (NP)
Entity type:Individual
Prefix:
First Name:SHERRIE
Middle Name:
Last Name:JACOBY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 CAMPANILE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92182-0001
Mailing Address - Country:US
Mailing Address - Phone:619-594-2866
Mailing Address - Fax:619-594-5613
Practice Address - Street 1:5500 CAMPANILE DR
Practice Address - Street 2:STUDENT HEALTH CENTER
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92182-0001
Practice Address - Country:US
Practice Address - Phone:619-594-2866
Practice Address - Fax:619-594-5613
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482381261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP482381OtherNP LICENSE