Provider Demographics
NPI:1912496142
Name:JACOBSEN, JACLYN ANN (MS)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:ANN
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17-12 HUNTER PL
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5242
Mailing Address - Country:US
Mailing Address - Phone:201-663-2530
Mailing Address - Fax:
Practice Address - Street 1:17-12 HUNTER PL
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5242
Practice Address - Country:US
Practice Address - Phone:201-663-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education