Basic Information
| Provider Information | |||||||||
| NPI: | 1336897263 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 W CONGRESS ST | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206703909 | ||||||||
| FaxNumber: | 5208849287 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W PRINCE RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857053526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206703909 | ||||||||
| FaxNumber: | 5203092560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86020648 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86020648 | 01 | AZ | COMMISSION ON DIETETIC REGISTRATION | OTHER |