Provider Demographics
NPI:1982661609
Name:JACOBS, NICOLETTA MARIA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:NICOLETTA
Middle Name:MARIA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 E 248TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1236
Mailing Address - Country:US
Mailing Address - Phone:216-299-6331
Mailing Address - Fax:
Practice Address - Street 1:1865 E 97TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1634
Practice Address - Country:US
Practice Address - Phone:216-721-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN110308164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2436475Medicare UPIN