Provider Demographics
NPI:1649707167
Name:JACOBSON, KATIE A
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 DALE LN E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2306
Mailing Address - Country:US
Mailing Address - Phone:1253-307-5245
Mailing Address - Fax:
Practice Address - Street 1:2918 DALE LN E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2306
Practice Address - Country:US
Practice Address - Phone:1253-307-5245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty