Basic Information
| Provider Information | |||||||||
| NPI: | 1063510550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LARSON | ||||||||
| OtherFirstName: | CARMEN | ||||||||
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| OtherCredential: | P.A.-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W | ||||||||
| Address2: | SUITE 110N | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 2550 UNIVERSITY AVE W | ||||||||
| Address2: | SUITE 110N | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551141052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 9775 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 127392200 | 05 | MN | MEDICAID |