Provider Demographics
NPI:1912486887
Name:JACOBS, JEANETTE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-1417
Mailing Address - Country:US
Mailing Address - Phone:270-259-5641
Mailing Address - Fax:270-259-5309
Practice Address - Street 1:901 WALLACE AVE
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754
Practice Address - Country:US
Practice Address - Phone:270-259-5641
Practice Address - Fax:270-259-5309
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012495363L00000X, 363LP0200X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics