Provider Demographics
NPI:1295033884
Name:MORAN-JACOBSON, LAISE MADELEINE (RN)
Entity Type:Individual
Prefix:
First Name:LAISE
Middle Name:MADELEINE
Last Name:MORAN-JACOBSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17069 VINTAGE DR
Mailing Address - Street 2:500 CROWN POINT CIRCLE #120
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-8798
Mailing Address - Country:US
Mailing Address - Phone:530-268-7367
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR # 120
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9514
Practice Address - Country:US
Practice Address - Phone:530-265-1437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190340163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse