Provider Demographics
NPI:1972385292
Name:JACOBS, ANGIE LYNN (LPN)
Entity type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:LYNN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:ANGIE
Other - Middle Name:LYNN
Other - Last Name:WHISNANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1328 CHEROKEE CIR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-5514
Mailing Address - Country:US
Mailing Address - Phone:864-209-7758
Mailing Address - Fax:
Practice Address - Street 1:CROSSROADS TREATMENT CENTERS
Practice Address - Street 2:209 OCONEE SQUARE DR
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46446164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse