Individual
GARY JACOBSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP, ARNP
Contact information
Practice address
176 1ST AVE. NORTH, PO BOX N, ILWACO, WA 98624
(360) 642-6316
Mailing address
176 1ST AVE. NORTH, PO BOX N, ILWACO, WA 98624
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
076035966N1
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
283341
—
OR
Enumeration date
07/11/2006
Last updated
01/06/2009
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