Provider Demographics
NPI:1689608010
Name:JACOBSON, PATRICIA A (APNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1648
Mailing Address - Country:US
Mailing Address - Phone:715-284-2003
Mailing Address - Fax:715-284-2008
Practice Address - Street 1:502 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1648
Practice Address - Country:US
Practice Address - Phone:715-284-2003
Practice Address - Fax:715-284-2008
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43899100Medicaid
WI43899100Medicaid