Provider Demographics
NPI:1922202282
Name:JACOBS, ROBIN (APRN)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 E GRAYSTONE WAY
Mailing Address - Street 2:STE 4
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2673
Mailing Address - Country:US
Mailing Address - Phone:801-502-4650
Mailing Address - Fax:
Practice Address - Street 1:1174 E GRAYSTONE WAY STE 4
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84106-2671
Practice Address - Country:US
Practice Address - Phone:801-502-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT190584-4405364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult