Provider Demographics
NPI:1487903605
Name:JACOB, SHARON MARGARET (MSN, MPH, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:MARGARET
Last Name:JACOB
Suffix:
Gender:F
Credentials:MSN, MPH, PMHNP-BC
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 1559
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33831-1559
Mailing Address - Country:US
Mailing Address - Phone:863-519-0575
Mailing Address - Fax:
Practice Address - Street 1:1835 GILMORE AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3017
Practice Address - Country:US
Practice Address - Phone:863-519-0575
Practice Address - Fax:863-582-9251
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9171943363LP0808X, 364SP0808X
FLAPRN9171943363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006495001Medicaid
FL006495000Medicaid
FLGP713ZMedicare PIN