Provider Demographics
NPI:1144270752
Name:JACOBS, JEANNINE M (CPNP)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:M
Last Name:JACOBS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:29 N ACADEMY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-2629
Practice Address - Country:US
Practice Address - Phone:864-331-1300
Practice Address - Fax:864-331-1447
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1686363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0833Medicaid
SCAA05837951Medicare PIN
SCAA05836904Medicare PIN