Provider Demographics
NPI:1780937359
Name:JACOB, SELIN K (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SELIN
Middle Name:K
Last Name:JACOB
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SELIN
Other - Middle Name:K
Other - Last Name:VARGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4221 VENETIAN LOOP
Mailing Address - Street 2:LAS CRUCES
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4126
Mailing Address - Country:US
Mailing Address - Phone:575-640-0052
Mailing Address - Fax:
Practice Address - Street 1:444 W FORT ST FL 2
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4535
Practice Address - Country:US
Practice Address - Phone:208-422-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02040363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily