Provider Demographics
NPI:1992133417
Name:JACOBS, LAVONDA (REGISTERED NURSE)
Entity type:Individual
Prefix:MRS
First Name:LAVONDA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 OLD MINDEN ROAD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-741-7314
Mailing Address - Fax:
Practice Address - Street 1:3022 OLD MINDEN ROAD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-741-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN110393163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse