Provider Demographics
NPI:1194905067
Name:JACOBS, CRYSTAL
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 OLD HICKORY BOULAVARD
Mailing Address - Street 2:APARTMENT 197
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076
Mailing Address - Country:US
Mailing Address - Phone:615-250-7274
Mailing Address - Fax:
Practice Address - Street 1:3310 PERIMETER HILL DRIVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211
Practice Address - Country:US
Practice Address - Phone:615-250-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator