Provider Demographics
NPI:1962851550
Name:JACOBSON, MARIA SHIELA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:SHIELA
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:775-781-0092
Mailing Address - Fax:800-514-2257
Practice Address - Street 1:1001 MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-3848
Practice Address - Country:US
Practice Address - Phone:775-781-0092
Practice Address - Fax:800-514-2257
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.014041363LF0000X
NVAPRN815052363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare UPIN