Provider Demographics
NPI:1215112982
Name:JAKUBOWSKI, LONI (RPAC)
Entity type:Individual
Prefix:MRS
First Name:LONI
Middle Name:
Last Name:JAKUBOWSKI
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:MISS
Other - First Name:LONI
Other - Middle Name:
Other - Last Name:JOOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2000 CIRCLE OF HOPE DR
Mailing Address - Street 2:RM 3360
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-5550
Mailing Address - Country:US
Mailing Address - Phone:801-213-4208
Mailing Address - Fax:801-585-0101
Practice Address - Street 1:2000 CIRCLE OF HOPE DR
Practice Address - Street 2:RM 3360
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-213-4208
Practice Address - Fax:801-585-0101
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012024363AM0700X
UT7892402363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical