Provider Demographics
NPI:1275883266
Name:JACOBSON, LANA RAE (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:MRS
First Name:LANA
Middle Name:RAE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 GOLF COURSE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3557
Mailing Address - Country:US
Mailing Address - Phone:218-322-4900
Mailing Address - Fax:
Practice Address - Street 1:1401 NW 9TH STREET
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-327-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120342-4163W00000X
MN0257857-22363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB0240767OtherDEA NUMBER-FEDERALLY