Provider Demographics
NPI:1952504292
Name:JACOBS, LESLIE CORINN (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:CORINN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3127
Mailing Address - Country:US
Mailing Address - Phone:636-239-8090
Mailing Address - Fax:636-390-7385
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8090
Practice Address - Fax:636-390-7385
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23936367500000X
MO2004034999367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN3303Medicaid
MOP00680827OtherRAILROAD MEDICARE