Provider Demographics
NPI:1750877825
Name:JACOBS, TRACY (FNP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:NEW LLANO
Mailing Address - State:LA
Mailing Address - Zip Code:71461-0130
Mailing Address - Country:US
Mailing Address - Phone:337-239-2207
Mailing Address - Fax:
Practice Address - Street 1:919 S. 10TH ST.
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446
Practice Address - Country:US
Practice Address - Phone:337-404-4106
Practice Address - Fax:337-404-4108
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10043363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner