Provider Demographics
NPI:1720638166
Name:DAWSON, JACOB JAY (LPN)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JAY
Last Name:DAWSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4516
Mailing Address - Country:US
Mailing Address - Phone:715-401-1840
Mailing Address - Fax:
Practice Address - Street 1:5120 STETTIN DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3824
Practice Address - Country:US
Practice Address - Phone:715-551-6827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI324142164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse