Provider Demographics
NPI:1558765636
Name:JACOBSON, AMY BROZICK (CPNP-BC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BROZICK
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:CPNP-BC
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:JOAN
Other - Last Name:BROZICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 CLARKE STREET
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:412-215-6709
Mailing Address - Fax:703-331-0959
Practice Address - Street 1:1830 TOWN CENTER DRIVE
Practice Address - Street 2:SUITE 205
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-435-3636
Practice Address - Fax:703-435-9145
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171122363LP0200X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics