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General NPI Number Information
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NPI Number | 1568554186
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Entity Type | Individual
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Provider Name | LISA JACOBS PMHNP
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Gender | Female
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 09/04/2015
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Provider Practice Location Address
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Address Line | 268 STILLWATER AVE
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City | BANGOR
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State | ME
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Zip | 04401-3945
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Country | US
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Telephone | 207-973-7306
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Fax | 207-973-6109
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Provider Business Mailing Address
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Address Line | 21823 E SANDY HILL LN
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City | SOUTH BEND
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State | IN
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Zip | 46628-9518
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Country | US
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Telephone | 574-807-5145
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | R038704
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License Number State | ME
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