Provider Demographics
NPI:1407835481
Name:JACOBSON, RENA L (AUD, FAAA, CCC-A)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:AUD, FAAA, CCC-A
Other - Prefix:MRS
Other - First Name:RENA
Other - Middle Name:L
Other - Last Name:GRIFFIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:341 STATE RD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-4319
Mailing Address - Country:US
Mailing Address - Phone:508-996-0389
Mailing Address - Fax:508-997-0429
Practice Address - Street 1:341 STATE RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-4319
Practice Address - Country:US
Practice Address - Phone:508-996-0389
Practice Address - Fax:508-997-0429
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA566231H00000X
RIAUD00159231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5104530Medicaid
MA5104530Medicaid
MAGR032364Medicare PIN
MAP57900Medicare UPIN