Provider Demographics
NPI:1457515884
Name:JACOBS, TINA LYNNE (NP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LYNNE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:950 N MERIDIAN ST
Mailing Address - Street 2:STE 500 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-962-4941
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-330-3688
Practice Address - Fax:812-355-3270
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002683A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903450Medicaid
IN549210NNNNMedicare PIN
INP01162923Medicare PIN
IN200903450Medicaid