Provider Demographics
NPI:1205563046
Name:JACOBSEN, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 E PIMA ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4322
Mailing Address - Country:US
Mailing Address - Phone:520-886-5315
Mailing Address - Fax:877-209-7377
Practice Address - Street 1:5902 E PIMA ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4322
Practice Address - Country:US
Practice Address - Phone:520-886-5315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant