Provider Demographics
NPI:1013553643
Name:JACOBSON, ALICIA MAY (LLPN)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MAY
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LLPN
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MILLAR FLETTY
Mailing Address - Street 1:1010 W MCLOUGHLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2314
Mailing Address - Country:US
Mailing Address - Phone:360-566-3254
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD BLDG 17
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3717
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60837151164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse