Provider Demographics
NPI:1194061226
Name:JACOBSON, DIANNE (RPH)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19021 HAMDEN LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-2133
Mailing Address - Country:US
Mailing Address - Phone:714-504-3326
Mailing Address - Fax:
Practice Address - Street 1:7860 NORWALK BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-2185
Practice Address - Country:US
Practice Address - Phone:562-692-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist