Provider Demographics
NPI:1093240491
Name:JACOBSON, TAMI JANINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TAMI
Middle Name:JANINE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 N VALLEJO WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3164
Mailing Address - Country:US
Mailing Address - Phone:909-702-7081
Mailing Address - Fax:
Practice Address - Street 1:1315 N VALLEJO WAY
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3164
Practice Address - Country:US
Practice Address - Phone:909-702-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11552363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health