Provider Demographics
NPI:1629574223
Name:JACOBSEN, ANDRE JACK
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:JACK
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 PROVIDENCE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4620
Mailing Address - Country:US
Mailing Address - Phone:907-561-1510
Mailing Address - Fax:
Practice Address - Street 1:3300 PROVIDENCE DR STE 205
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4620
Practice Address - Country:US
Practice Address - Phone:907-561-1510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK200882207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology