Provider Demographics
NPI:1801673017
Name:JACOBSON, CARLENE (RN)
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 W 400 N
Mailing Address - Street 2:
Mailing Address - City:MARRIOTT SLATERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3412
Mailing Address - Country:US
Mailing Address - Phone:801-205-3866
Mailing Address - Fax:
Practice Address - Street 1:670 E 3900 S STE 310
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1981
Practice Address - Country:US
Practice Address - Phone:801-266-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA846611163W00000X
UT7612108-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse