Provider Demographics
NPI:1922265800
Name:JACOBSEN, LAVONNE (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:LAVONNE
Other - Middle Name:
Other - Last Name:WILLENKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CNM
Mailing Address - Street 1:3208 AMBERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2133
Mailing Address - Country:US
Mailing Address - Phone:405-509-4661
Mailing Address - Fax:800-865-6885
Practice Address - Street 1:3208 AMBERWOOD CT
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-2133
Practice Address - Country:US
Practice Address - Phone:405-509-4661
Practice Address - Fax:800-865-6885
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW621367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW006210OtherMEDI-CAL
CAZZZ37640ZOtherBLUE SHIELD
OKR 0101207OtherOKLAHOMA ADVANCED PRACTICE REGISTERED NURSE LICENSE
CAZZZ37640ZOtherBLUE SHIELD