Provider Demographics
NPI:1619335676
Name:JACOBSON, RICKY (RN, MSN)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GREEN VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1515
Mailing Address - Country:US
Mailing Address - Phone:215-459-3547
Mailing Address - Fax:215-643-3712
Practice Address - Street 1:280 PENNBROOK PKWY
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-3843
Practice Address - Country:US
Practice Address - Phone:215-643-1811
Practice Address - Fax:215-643-3712
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA70383105133NN1002X
PARN162041L163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA70383105OtherAMERICAN ASSOCIATION OF DRUGLESS PRACTIONERS