Provider Demographics
NPI:1366037160
Name:JACOBS, SANDRA SUE (APRN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:SUE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11613 MAPLE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2212
Mailing Address - Country:US
Mailing Address - Phone:502-214-0206
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRINGHURST BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6137
Practice Address - Country:US
Practice Address - Phone:502-394-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY283Q00000X
KY3015884363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No283Q00000XHospitalsPsychiatric Hospital