1174698856 NPI number — MRS. RENEE LOUISE ANN JACOBSEN MS CCC SLP

Table of content: MRS. RENEE LOUISE ANN JACOBSEN MS CCC SLP (NPI 1174698856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174698856 NPI number — MRS. RENEE LOUISE ANN JACOBSEN MS CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBSEN
Provider First Name:
RENEE
Provider Middle Name:
LOUISE ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILL
Provider Other First Name:
RENEE
Provider Other Middle Name:
LOUISE ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS CCC SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174698856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
276 SPRUCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARROYO GRANDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-709-3045
Provider Business Mailing Address Fax Number:
805-473-9096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 WEST BURTON MESA BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-733-4542
Provider Business Practice Location Address Fax Number:
805-733-4392
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP13476 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0663623 . This is a "TRIWEST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GSP000390 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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