MEDICARE: VICTORIA EDUARDOVNA JACOBS NP

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
1	363L00000X	Nurse Practitioner	5142656-4405	UT
2	363LF0000X	Family Nurse Practitioner	5142656-4405	UT
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5142656-4405	UT

General Provider Information

NPI Number	:	1730217167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA EDUARDOVNA JACOBS NP

Provider Business Mailing Address
First Line	:	817 W 700 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-1405
Country	:	US
Telephone Number	:	801-712-8850
Fax Number	:

Provider Business Practice Location Address
First Line	:	817 W 700 S
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84104-1405
Country	:	US
Telephone Number	:	801-712-8850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	12/04/2020

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