Basic Information
| Provider Information | |||||||||
| NPI: | 1336376128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | LYNNE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8745 COUNTY ROAD 9 S | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811019610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893671 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8745 COUNTY ROAD 9 S | ||||||||
| Address2: | |||||||||
| City: | ALAMOSA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811019610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195893671 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 107198 | CO | N | Nursing Service Providers | Registered Nurse | 363L00000X | NP10040 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 107198 | 01 | CO | RN | OTHER | 32658044 | 05 | CO | MEDICAID |