Individual
MARY AMANDA JACOBS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
200 SCENERY DR., STATE COLLEGE, PA 16801-5602
(814) 231-4560
(814) 231-6246
Mailing address
100 N ACADEMY AVE, DANVILLE, PA 17822-4903
(570) 271-6144
(570) 271-6578
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
46763
MN
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
MD437386
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
102337081
—
PA
05
—
35163500
—
WI
05
—
699485700
—
MN
05
—
ENROLLED
—
IA
01
—
P00333407
RAILROAD MEDICARE
MN
Enumeration date
12/21/2005
Last updated
08/05/2020
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