Provider Demographics
NPI:1700101748
Name:JACOBSON, MAUREEN DENISE (RD , LD)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:DENISE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RD , LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2420 LAKE AVE
Mailing Address - Street 2:ASHTABULA
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4954
Mailing Address - Country:US
Mailing Address - Phone:440-997-2262
Mailing Address - Fax:440-997-6360
Practice Address - Street 1:2420 LAKE AVE
Practice Address - Street 2:ASHTABULA
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4954
Practice Address - Country:US
Practice Address - Phone:440-997-2262
Practice Address - Fax:440-997-6360
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.3968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered