Provider Demographics
NPI:1720111990
Name:JACOBS, BRENDA JOYCE (APN)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JOYCE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5414
Practice Address - Street 1:535 JORDAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5714
Practice Address - Country:US
Practice Address - Phone:870-367-6246
Practice Address - Fax:855-926-7383
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182729758Medicaid