Basic Information
| Provider Information | |||||||||
| NPI: | 1457515884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N MERIDIAN ST | ||||||||
| Address2: | STE 500 - PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179624941 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123303688 | ||||||||
| FaxNumber: | 8123553270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2008 | ||||||||
| LastUpdateDate: | 05/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71002683A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200903450 | 05 | IN | MEDICAID |