Provider Demographics
NPI:1336257229
Name:JACOBSON, INGER (NP)
Entity Type:Individual
Prefix:
First Name:INGER
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 PLAZA DR
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4158
Mailing Address - Country:US
Mailing Address - Phone:715-847-2311
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4158
Practice Address - Country:US
Practice Address - Phone:715-847-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI202152363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43890100Medicaid
WI011939295Medicare ID - Type Unspecified
S75447Medicare UPIN