Provider Demographics
NPI:1720198906
Name:JAKUBCO, LYNDA L (CRNA)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:L
Last Name:JAKUBCO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3625
Mailing Address - Country:US
Mailing Address - Phone:570-621-5000
Mailing Address - Fax:570-621-5589
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-621-5000
Practice Address - Fax:570-621-5589
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN323767L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ50157Medicare UPIN
PA093783Medicare ID - Type Unspecified
PA390030Medicare PIN