Healthcare Provider Details

I. General information

NPI: 1134917370
Provider Name (Legal Business Name): AMANDA JACOBSEN APN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0N597 FIELDSTONE LN
GENEVA IL
60134-3527
US

IV. Provider business mailing address

0N597 FIELDSTONE LN
GENEVA IL
60134-3527
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209035343
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: