Provider Demographics
NPI:1700985520
Name:JACOBSEN, LAURA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACOBSEN
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 1:725 IRVING AVE
Mailing Address - Street 2:PHYSICIAN'S OFFICE BUILDING, SUITE 112
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-464-6395
Mailing Address - Fax:315-464-6398
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:PHYSICIAN'S OFFICE BUILDING, SUITE 112
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-464-6395
Practice Address - Fax:315-464-6398
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF331901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S60985Medicare UPIN
NYCC7932Medicare ID - Type Unspecified
NY00355266Medicare ID - Type Unspecified