Provider Demographics
NPI:1275759722
Name:JACOBSEN, KATHY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KATHY
Other - Middle Name:ANN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1170 N GILBERT RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2340
Mailing Address - Country:US
Mailing Address - Phone:480-507-1807
Mailing Address - Fax:480-813-5833
Practice Address - Street 1:1170 N GILBERT RD
Practice Address - Street 2:SUITE 125
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2340
Practice Address - Country:US
Practice Address - Phone:480-507-1807
Practice Address - Fax:480-813-5833
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist