Provider Demographics
NPI:1235615105
Name:JACOBSON, NICOLE LEEANN (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEEANN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:1720 2ND ST
Practice Address - Street 2:
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-1910
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60861760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist