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 1:1405 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4608
Mailing Address - Country:US
Mailing Address - Phone:502-896-0495
Mailing Address - Fax:502-896-0219
Practice Address - Street 1:1405 BROWNS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4608
Practice Address - Country:US
Practice Address - Phone:502-896-0495
Practice Address - Fax:502-896-0219
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital