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NPI Code Detail

MEDICARE: LISA JACOBS PMHNP

MEDICARE: LISA JACOBS PMHNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LP0808XPsychiatric/Mental Health Nurse PractitionerR038704ME

General Provider Information

NPI Number : 1568554186
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA JACOBS PMHNP
Provider Business Mailing Address
First Line : 21823 E SANDY HILL LN
Second Line :
City : SOUTH BEND
State : IN
Zip : 46628-9518
Country : US
Telephone Number : 574-807-5145
Fax Number :
Provider Business Practice Location Address
First Line : 268 STILLWATER AVE
Second Line :
City : BANGOR
State : ME
Zip : 04401-3945
Country : US
Telephone Number : 207-973-7306
Fax Number : 207-973-6109
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/29/2006
Last Update Date : 09/04/2015

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