Basic Information
| Provider Information | |||||||||
| NPI: | 1386945004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSEN | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14500 99TH AVE N STE 100 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7638981000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2010 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD60825838 | WA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | MD60825838 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 1386945004 | 05 | WA | MEDICAID |