Basic Information
| Provider Information | |||||||||
| NPI: | 1891204152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | JASMINE | ||||||||
| MiddleName: | KEAMBER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCKINLEY | ||||||||
| OtherFirstName: | JASMINE | ||||||||
| OtherMiddleName: | KEAMBER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 SUN TEMPLE DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 357588643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562883333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1615 KATHY LN SW STE 102 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356031026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2566864441 | ||||||||
| FaxNumber: | 2566864443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2017 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 8033-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.