Provider Demographics
NPI:1114975190
Name:JACOBSEN, ANGELA MARIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:NAGY-JACOBSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:833 W SOLANO DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1643
Mailing Address - Country:US
Mailing Address - Phone:219-614-7265
Mailing Address - Fax:
Practice Address - Street 1:19001 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5036
Practice Address - Country:US
Practice Address - Phone:623-293-4400
Practice Address - Fax:623-293-4405
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5609934-1701183500000X
IN26019903A183500000X
AZ12512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist