Provider Demographics
NPI:1821191164
Name:JACOBS, STEVE ALTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEVE
Middle Name:ALTON
Last Name:JACOBS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5523 LAKE SIDE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5548
Mailing Address - Country:US
Mailing Address - Phone:318-746-4254
Mailing Address - Fax:
Practice Address - Street 1:510 EAST STONER AVE.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4295
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-429-5710
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN035529367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered