Provider Demographics
NPI:1609249275
Name:JACOBSEN, KANUKAYI
Entity Type:Individual
Prefix:
First Name:KANUKAYI
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NE 16TH AVE
Mailing Address - Street 2:APT 106
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3088
Mailing Address - Country:US
Mailing Address - Phone:503-310-8581
Mailing Address - Fax:
Practice Address - Street 1:11818 SE MILL PLAIN BLVD
Practice Address - Street 2:213
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5089
Practice Address - Country:US
Practice Address - Phone:360-836-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program