Provider Demographics
NPI:1871147819
Name:JACOBS, JAMIE LEA (FNP-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859-1213
Mailing Address - Country:US
Mailing Address - Phone:618-643-2361
Mailing Address - Fax:
Practice Address - Street 1:1112 OAK ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821
Practice Address - Country:US
Practice Address - Phone:618-382-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily