Provider Demographics
NPI:1134622806
Name:JACOBS, JENNIFER (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
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 1:892 RIDGEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-1737
Mailing Address - Country:US
Mailing Address - Phone:479-970-8086
Mailing Address - Fax:
Practice Address - Street 1:1601 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ATKINS
Practice Address - State:AR
Practice Address - Zip Code:72823-3234
Practice Address - Country:US
Practice Address - Phone:479-641-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily