Provider Demographics
NPI:1679794358
Name:JACOBS, LAURA CHARLOTTE (OTR)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CHARLOTTE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CALLAWAY CIR
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-9702
Mailing Address - Country:US
Mailing Address - Phone:276-322-1976
Mailing Address - Fax:
Practice Address - Street 1:20 WESTWOOD MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2003
Practice Address - Country:US
Practice Address - Phone:276-322-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003857225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist