Healthcare Provider Details

I. General information

NPI: 1649480070
Provider Name (Legal Business Name): PAMELA JEAN JACOBSON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N TUSTIN AVE SUITE 380
SANTA ANA CA
92705-3813
US

IV. Provider business mailing address

400 N TUSTIN AVE SUITE 380
SANTA ANA CA
92705-3813
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-2233
  • Fax: 714-730-2768
Mailing address:
  • Phone: 714-730-2233
  • Fax: 714-730-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC10904
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: