Individual
TINA LYNNE JACOBS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
550 S LANDMARK AVE, BLOOMINGTON, IN 47403-3239
(812) 330-3688
(812) 355-3270
Mailing address
950 N MERIDIAN ST, STE 500 - PROVIDER ENROLLMENT, INDIANAPOLIS, IN 46204-3908
(317) 962-4941
(317) 962-4950
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
71002683A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200903450
—
IN
Enumeration date
07/15/2008
Last updated
05/29/2013
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