Provider Demographics
NPI:1114529781
Name:JACOBSON, TRACY (NP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
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 1:333 N SUMMIT ST FL 15
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:800-427-1902
Mailing Address - Fax:419-531-2664
Practice Address - Street 1:6000 E STATE ST STE 1
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2521
Practice Address - Country:US
Practice Address - Phone:800-427-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily