Healthcare Provider Details

I. General information

NPI: 1548651342
Provider Name (Legal Business Name): JACOB E. SWENSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST DEPARTMENT OF ANESTHESIOLOGY
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 804-628-6990
  • Fax: 804-628-6932
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024172374
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: