Healthcare Provider Details

I. General information

NPI: 1154590511
Provider Name (Legal Business Name): MARY JACOBSEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2008
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4126
US

IV. Provider business mailing address

2575 N COURTENAY PKWY
MERRITT ISLAND FL
32953-4126
US

V. Phone/Fax

Practice location:
  • Phone: 321-639-5787
  • Fax: 321-454-7115
Mailing address:
  • Phone: 321-639-5787
  • Fax: 321-454-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN645881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: