Provider Demographics
NPI:1639625114
Name:JACOBSEN, STEPHEN (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 SE 26TH AVE
Mailing Address - Street 2:APT. G22
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-9600
Mailing Address - Country:US
Mailing Address - Phone:443-812-2240
Mailing Address - Fax:
Practice Address - Street 1:10500 SE 26TH AVE
Practice Address - Street 2:APT. G22
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-9600
Practice Address - Country:US
Practice Address - Phone:443-812-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC177271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist