Provider Demographics
NPI:1871758102
Name:JACOBS, LISA ELLEN (APRN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ELLEN
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 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPOO8576363LP0222X
FLAPRN11001508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102348200Medicaid