Provider Demographics
NPI:1255952941
Name:JACOBSEN, GRETA
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:JACOBSEN
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 1:1313 E HERNDON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3306
Mailing Address - Country:US
Mailing Address - Phone:559-450-4637
Mailing Address - Fax:
Practice Address - Street 1:2021 SANTA MONICA BLVD STE 625E
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2169
Practice Address - Country:US
Practice Address - Phone:310-829-8948
Practice Address - Fax:424-212-5937
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA184055207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program