Provider Demographics
NPI:1619146503
Name:JACOBSON, AMY ANN (NP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ANN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 UCLA MEDICAL PLZ STE 120
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8344
Mailing Address - Country:US
Mailing Address - Phone:310-794-0242
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ STE 120
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1275
Practice Address - Country:US
Practice Address - Phone:310-794-0242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17594363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health