Provider Demographics
NPI:1396718599
Name:JACOBS, SANDRA J (CRNA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:JACOBS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 NE 175TH ST
Mailing Address - Street 2:APT A302
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-3567
Mailing Address - Country:US
Mailing Address - Phone:425-274-5046
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004485367500000X
NMCRNA00524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2701JAOtherINDIVIDUAL BLUE SHIELD
WA9612078Medicaid
WA9612078Medicaid
WA2701JAOtherINDIVIDUAL BLUE SHIELD