Provider Demographics
NPI:1265058325
Name:JACOBSON, HEATHERE MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:HEATHERE
Middle Name:MARIE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 ASH AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9618
Mailing Address - Country:US
Mailing Address - Phone:218-259-9154
Mailing Address - Fax:
Practice Address - Street 1:1130 E 37TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2962
Practice Address - Country:US
Practice Address - Phone:218-259-9154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist