Provider Demographics
NPI:1346254059
Name:JACOBSON, AMY P (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:P
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3049
Mailing Address - Country:US
Mailing Address - Phone:413-586-8156
Mailing Address - Fax:413-789-8048
Practice Address - Street 1:69 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3049
Practice Address - Country:US
Practice Address - Phone:413-586-8156
Practice Address - Fax:413-586-2992
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP90086Medicare UPIN
MAAP0876Medicare ID - Type Unspecified