Provider Demographics
NPI:1043298193
Name:JACOBSON, SANDRA A (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:F
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 53568
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-3568
Mailing Address - Country:US
Mailing Address - Phone:623-544-5075
Mailing Address - Fax:
Practice Address - Street 1:10515 W SANTA FE DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3020
Practice Address - Country:US
Practice Address - Phone:623-875-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-08
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD113532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z124143Medicare PIN
RI007056457Medicare ID - Type Unspecified