Provider Demographics
NPI:1700425154
Name:JACOBSON, MARY BETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2192 LEWIS DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-6141
Mailing Address - Country:US
Mailing Address - Phone:216-224-4366
Mailing Address - Fax:
Practice Address - Street 1:2192 LEWIS DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-6141
Practice Address - Country:US
Practice Address - Phone:216-221-5182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical