Provider Demographics
NPI:1649703307
Name:JACOBS, TINA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:JESELUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10269 W WESLEY PL
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-3074
Mailing Address - Country:US
Mailing Address - Phone:414-807-7941
Mailing Address - Fax:
Practice Address - Street 1:304 INVERNESS WAY S STE 312
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-5826
Practice Address - Country:US
Practice Address - Phone:303-218-6657
Practice Address - Fax:720-398-9156
Is Sole Proprietor?:No
Enumeration Date:2017-04-09
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant