Provider Demographics
NPI:1487654315
Name:JACOBS, TINA HARRIS (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:HARRIS
Last Name:JACOBS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-1800
Mailing Address - Country:US
Mailing Address - Phone:910-844-5253
Mailing Address - Fax:910-844-3290
Practice Address - Street 1:610 E MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364-1800
Practice Address - Country:US
Practice Address - Phone:910-844-5253
Practice Address - Fax:910-844-3290
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201337363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2599520Medicare PIN
NC2599520BMedicare PIN
NCP26975Medicare UPIN
NC2599520AMedicare PIN
NC2599520CMedicare PIN