Provider Demographics
NPI:1356311781
Name:JACOBSEN, PEGGY ELENE (RN)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ELENE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:PEGGY
Other - Middle Name:GAMBEE
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:7454 S 2405 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-3114
Mailing Address - Country:US
Mailing Address - Phone:801-563-0998
Mailing Address - Fax:
Practice Address - Street 1:195 W 7200 S
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3703
Practice Address - Country:US
Practice Address - Phone:801-565-6900
Practice Address - Fax:801-569-0899
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1927543102163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942938348014OtherCHAMPUS
UT751659OtherDESERET MUTUAL
UT107032218101OtherINTERMTN. HEALTH CARE