Provider Demographics
NPI:1063510550
Name:JACOBSON, CARMEN JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:JEAN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2550 UNIVERSITY AVE W
Mailing Address - Street 2:SUITE 110N
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1052
Mailing Address - Country:US
Mailing Address - Phone:651-602-5311
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 110N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-602-5311
Practice Address - Fax:651-222-6786
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9775363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN127392200Medicaid
MN970001579Medicare PIN
MN970001579Medicare ID - Type Unspecified
MNP79290Medicare UPIN