Provider Demographics
NPI:1801404579
Name:JACOBSEN, GRACE L (PA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:L
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3841 PIPER ST STE T100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4674
Mailing Address - Country:US
Mailing Address - Phone:907-550-2233
Mailing Address - Fax:907-771-6715
Practice Address - Street 1:3841 PIPER ST STE T100
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4674
Practice Address - Country:US
Practice Address - Phone:907-561-3211
Practice Address - Fax:907-771-6715
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK209899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant