Basic Information
| Provider Information | |||||||||
| NPI: | 1407835481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | RENA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD, FAAA, CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIFFIS | ||||||||
| OtherFirstName: | RENA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 341 STATE RD | ||||||||
| Address2: | |||||||||
| City: | DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027474319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089960389 | ||||||||
| FaxNumber: | 5089970429 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 STATE RD | ||||||||
| Address2: | |||||||||
| City: | DARTMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027474319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089960389 | ||||||||
| FaxNumber: | 5089970429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 566 | MA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 5104530 | 05 | MA | MEDICAID |