Provider Demographics
NPI:1003054651
Name:JACOBSEN, CARISSA ANN (LMP)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 262
Mailing Address - Street 2:
Mailing Address - City:N. LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98259
Mailing Address - Country:US
Mailing Address - Phone:425-422-9956
Mailing Address - Fax:
Practice Address - Street 1:460 NE 70TH STREET
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115
Practice Address - Country:US
Practice Address - Phone:206-522-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60040731225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist