Healthcare Provider Details

I. General information

NPI: 1750101648
Provider Name (Legal Business Name): JACOBB SEMPLE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SUNNYBROOK RD STE 100
RALEIGH NC
27610-1874
US

IV. Provider business mailing address

166 ARROW LN
MIDDLESEX NC
27557-9451
US

V. Phone/Fax

Practice location:
  • Phone: 919-322-4800
  • Fax:
Mailing address:
  • Phone: 440-344-1419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: