Provider Demographics
NPI:1669593489
Name:JACOBS, PENNY LYNN (CRNP)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:LYNN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
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Mailing Address - Street 1:4101 OGLETHORPE ST
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3026
Mailing Address - Country:US
Mailing Address - Phone:301-779-8715
Mailing Address - Fax:301-314-3596
Practice Address - Street 1:UNIVERSITY OF MARYLAND HEALTH CTR
Practice Address - Street 2:BLDG 140 CAMPUS DR
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20742-0001
Practice Address - Country:US
Practice Address - Phone:301-314-8190
Practice Address - Fax:301-314-3596
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR078476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MJ0898049OtherDEA#