=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548646946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTINA LOUISE JACOBS NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2015
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10600 MASTIN ST
-----------------------------------------------------
City | OVERLAND PARK
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66212-5723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-469-6647
-----------------------------------------------------
Fax | 913-338-1311
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 741331
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-469-0503
-----------------------------------------------------
Fax | 913-359-1200
-----------------------------------------------------
=====================================================
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 | 53-76877
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------