Provider Demographics
NPI:1588836654
Name:JACOBSON, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9135 SW BARNES RD STE 985
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6699
Mailing Address - Country:US
Mailing Address - Phone:503-297-3336
Mailing Address - Fax:503-297-3338
Practice Address - Street 1:9135 SW BARNES RD STE 985
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6699
Practice Address - Country:US
Practice Address - Phone:503-297-3336
Practice Address - Fax:032-973-3338
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA174781207RE0101X, 363A00000X
WI2663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588836654Medicaid
WI73601 1994Medicare PIN