Basic Information
| Provider Information | |||||||||
| NPI: | 1215924956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
| FaxNumber: | 6147224565 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
| FaxNumber: | 6147224565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 02/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APRN.CNP.03893 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LC0200X | RN190931 NP3893 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2246500 | 05 | OH | MEDICAID | 78012903 | 05 | KY | MEDICAID | 7102084000 | 05 | WV | MEDICAID |