Provider Demographics
NPI:1619196490
Name:JACOBSON, RENEE ROSE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:ROSE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:RENEE
Other - Middle Name:ROSE
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:3335 S AIRPORT RD W STE 7B
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7928
Mailing Address - Country:US
Mailing Address - Phone:231-463-1611
Mailing Address - Fax:231-947-1284
Practice Address - Street 1:3335 S AIRPORT RD W STE 7B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7928
Practice Address - Country:US
Practice Address - Phone:231-463-1611
Practice Address - Fax:231-947-1284
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704147470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily