MEDICARE: TINA HARRIS JACOBS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	201337	NC

General Provider Information

NPI Number	:	1487654315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA HARRIS JACOBS FNP

Provider Business Mailing Address
First Line	:	610 E MARTIN LUTHER KING JR DR
Second Line	:
City	:	MAXTON
State	:	NC
Zip	:	28364-1800
Country	:	US
Telephone Number	:	910-844-5253
Fax Number	:	910-844-3290

Provider Business Practice Location Address
First Line	:	610 E MARTIN LUTHER KING JR DR
Second Line	:
City	:	MAXTON
State	:	NC
Zip	:	28364-1800
Country	:	US
Telephone Number	:	910-844-5253
Fax Number	:	910-844-3290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	07/24/2007

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