Healthcare Provider Details

I. General information

NPI: 1134739386
Provider Name (Legal Business Name): JACOB TYREE CASH PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 FEDERAL ST
LYNCHBURG VA
24504-2306
US

IV. Provider business mailing address

358 BEARFIELD RD
AMHERST VA
24521-3986
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-5967
  • Fax:
Mailing address:
  • Phone: 434-941-8091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024179880
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: