Provider Demographics
NPI:1063127967
Name:JACOBS, RANDI (APRN)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:859-967-5748
Mailing Address - Fax:859-967-5473
Practice Address - Street 1:170 N EAGLE CREEK DR STE 104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-9087
Practice Address - Country:US
Practice Address - Phone:859-967-5848
Practice Address - Fax:859-967-5473
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018860363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100874920Medicaid