Individual
ALICE KELLEY JACOBSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
244 WESTERN AVE STE 100, SOUTH PORTLAND, ME 04106
(207) 775-3446
Mailing address
244 WESTERN AVE STE 100, SOUTH PORTLAND, ME 04106-2430
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1679687594
—
ME
Enumeration date
07/27/2016
Last updated
11/15/2019
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