Healthcare Provider Details

I. General information

NPI: 1255009486
Provider Name (Legal Business Name): NATHAN JACOBS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 636324
CINCINNATI OH
45263-6324
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-9010
  • Fax: 859-301-9018
Mailing address:
  • Phone: 859-301-9010
  • Fax: 859-301-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3015130
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0035789
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015130
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: