Provider Demographics
NPI:1063949790
Name:JACOBSON, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3107
Mailing Address - Country:US
Mailing Address - Phone:740-304-9309
Mailing Address - Fax:
Practice Address - Street 1:1550 SHERIDAN DR
Practice Address - Street 2:202
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-1381
Practice Address - Country:US
Practice Address - Phone:740-654-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020843363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner