Provider Demographics
NPI:1669242186
Name:JACOBS, LEANNA
Entity type:Individual
Prefix:
First Name:LEANNA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MOUNT TABOR RD
Mailing Address - Street 2:
Mailing Address - City:RED SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28377-6322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 CANDY PARK RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-9120
Practice Address - Country:US
Practice Address - Phone:910-512-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant