Healthcare Provider Details

I. General information

NPI: 1376454827
Provider Name (Legal Business Name): MIRANDA JACOBSEN PA STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 108TH AVE NE
KIRKLAND WA
98033-7050
US

IV. Provider business mailing address

49 MOUNTAIN RD
IRVINGTON NY
10533-1405
US

V. Phone/Fax

Practice location:
  • Phone: 914-815-1897
  • Fax:
Mailing address:
  • Phone: 914-815-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: