Provider Demographics
NPI:1356377246
Name:JACOBSEN, REGINA MARIE (CRNA)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:REGINA
Other - Middle Name:MARIE
Other - Last Name:PEROZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:115 BALFOUR AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-2304
Mailing Address - Country:US
Mailing Address - Phone:856-313-2401
Mailing Address - Fax:
Practice Address - Street 1:65 JIMMIE LEEDS ROAD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NJ
Practice Address - Zip Code:08240
Practice Address - Country:US
Practice Address - Phone:609-748-7088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR07354500367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered