Healthcare Provider Details

I. General information

NPI: 1144030925
Provider Name (Legal Business Name): LUCAS JACOBSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 STEVENS AVE STE 206
SOLANA BEACH CA
92075-2065
US

IV. Provider business mailing address

105 VIA GALICIA
SAN CLEMENTE CA
92672-3827
US

V. Phone/Fax

Practice location:
  • Phone: 858-617-0004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038901
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number39796
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number281472
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: