Provider Demographics
NPI:1023191640
Name:JACOBSON, REBECCA (FNP-C, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:FNP-C, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CO
Mailing Address - Zip Code:80446-1169
Mailing Address - Country:US
Mailing Address - Phone:970-887-5800
Mailing Address - Fax:
Practice Address - Street 1:1000 GRANBY PARK DRIVE SOUTH
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446
Practice Address - Country:US
Practice Address - Phone:970-887-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO168869363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72428864Medicaid
CO72428864Medicaid