Provider Demographics
NPI:1407299472
Name:JACOBS, MIKKI D (APN)
Entity Type:Individual
Prefix:
First Name:MIKKI
Middle Name:D
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 PARK WEST BLVD STE 402
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4312
Mailing Address - Country:US
Mailing Address - Phone:865-690-3003
Mailing Address - Fax:865-690-6404
Practice Address - Street 1:9330 PARK WEST BLVD STE 402
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4312
Practice Address - Country:US
Practice Address - Phone:865-690-3003
Practice Address - Fax:865-690-6404
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17489363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013344Medicaid
TN10350I9767Medicare PIN