=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144030925
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCAS JACOBSEN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2025
-----------------------------------------------------
Last Update Date | 04/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 461 21ST AVE S
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37240-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-322-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 VIA GALICIA
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92672-3827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95038901
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 39796
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 281472
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------