Provider Demographics
NPI:1962650069
Name:JACOBSON, CHERILYN A (PA)
Entity Type:Individual
Prefix:MRS
First Name:CHERILYN
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:CHERILYN
Other - Middle Name:A
Other - Last Name:VAIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3830 W 121ST PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-7921
Mailing Address - Country:US
Mailing Address - Phone:303-410-8041
Mailing Address - Fax:
Practice Address - Street 1:3830 W 121ST PL
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-7921
Practice Address - Country:US
Practice Address - Phone:303-410-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3708363A00000X
COPA.0005795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant