Provider Demographics
NPI:1508966458
Name:JACOBSON, STEPHANIE (CNM, WHNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MCNAMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, WHNP
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6748
Mailing Address - Fax:619-543-3183
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:858-249-6748
Practice Address - Fax:619-543-3183
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12690363LX0001X
CA1512367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41890Medicare UPIN
NM63639858Medicaid
NM348512202Medicare PIN