Provider Demographics
NPI:1497802920
Name:JACOBSON, KIPPEN MARSHALL (NP C)
Entity Type:Individual
Prefix:
First Name:KIPPEN
Middle Name:MARSHALL
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:NP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:GLENNALLEN
Mailing Address - State:AK
Mailing Address - Zip Code:99588-0589
Mailing Address - Country:US
Mailing Address - Phone:907-822-3203
Mailing Address - Fax:907-822-5805
Practice Address - Street 1:MILE 187 GLENN HWY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588-0589
Practice Address - Country:US
Practice Address - Phone:907-822-3203
Practice Address - Fax:907-822-5805
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1497802920OtherNPI NUMBER
AKK161914OtherMEDICARE PTAN
AKRH047FQMedicaid
AKK0000WCHWPMedicare PIN
AKK161914OtherMEDICARE PTAN
AKRH047FQMedicaid