Provider Demographics
NPI:1003909193
Name:JACOBSON, KENNETH H (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2345207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124217OtherSUPERIOR PIN
1447220850OtherGRP NPI NUMBER
TX1950571OtherUHC PIN
TX10030778OtherAMERIGROUP PIN
TX7067290OtherAETNA PIN
TX0324290OtherCIGNA PIN
TX147834901Medicaid
TX1192925OtherFIRSTHEALTH PIN
TX140442853Medicaid
TX00N47FOtherBCBSTX GRP PIN
TX147834902Medicaid
TX115891100OtherFIRSTCARE PIN
TX137345809Medicaid
TX88413YOtherBCBSTX IND PIN
TX9187586OtherPHCS PIN
TX9187586OtherPHCS PIN
TX147834901Medicaid
TX1192925OtherFIRSTHEALTH PIN