Healthcare Provider Details

I. General information

NPI: 1285345488
Provider Name (Legal Business Name): THOMAS JOSEPH JACOBSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-3392
US

IV. Provider business mailing address

1808 NW 177TH TER
EDMOND OK
73012-6931
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-7878
  • Fax:
Mailing address:
  • Phone: 405-696-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR0126117
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number71305
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: