Provider Demographics
NPI:1366178071
Name:JACOBSEN, NICHOLE MICHELLE (RN)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:MICHELLE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WIRELESS BLVD
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3974
Mailing Address - Country:US
Mailing Address - Phone:631-853-7373
Mailing Address - Fax:
Practice Address - Street 1:50 WHEELER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2154
Practice Address - Country:US
Practice Address - Phone:631-538-0505
Practice Address - Fax:631-439-0768
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY728838-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse