Provider Demographics
NPI:1003360991
Name:JACOBSON, MATTHEW (APRN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 20TH STREET
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82440-2812
Mailing Address - Country:US
Mailing Address - Phone:307-269-0947
Mailing Address - Fax:
Practice Address - Street 1:108 20TH STREET
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82440-2812
Practice Address - Country:US
Practice Address - Phone:307-269-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY25098.1537363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily