Provider Demographics
NPI:1063765451
Name:JACOBS, EDWINA YVONNE (FNP)
Entity type:Individual
Prefix:MRS
First Name:EDWINA
Middle Name:YVONNE
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 1:615 W ROUND BUNCH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-2434
Mailing Address - Country:US
Mailing Address - Phone:409-735-7305
Mailing Address - Fax:888-972-9401
Practice Address - Street 1:615 W ROUND BUNCH RD
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-2434
Practice Address - Country:US
Practice Address - Phone:409-735-7305
Practice Address - Fax:888-972-9401
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX654339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP122669OtherAPRN
TX13293OtherPRESCRIPTIVE AUTHORIZATION
TX654339OtherBOARD OF NURSING FAMILY PRACTICE NURSE PRACTITIONER LICENSE
TXMJ2767448OtherDEA