=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104456565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON ROBERT JACOBSON APRN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2020
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12428 SAN JOSE BLVD STE 4
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32223-8617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-403-9466
-----------------------------------------------------
Fax | 602-708-5615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1119 NATURES HAMMOCK RD N
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-2891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-403-9466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 13915782-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 870426
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AC003602
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 294465
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 0024193643
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP61509339
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11003000
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN11003000
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95032140
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1170150
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 10020817
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 8155
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | F352405-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------