Provider Demographics
NPI:1942235718
Name:JACOBSEN, GARY (FNP, ARNP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:FNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 1ST AVE. NORTH
Mailing Address - Street 2:PO BOX N
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 1ST AVE. NORTH
Practice Address - Street 2:PO BOX N
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-6316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR076035966N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR283341Medicaid
OR283341Medicaid
ORRR PTAN P00253534Medicare PIN
R94190Medicare UPIN