Provider Demographics
NPI:1043514391
Name:DONALD M. JACOBSON, MD SC
Entity Type:Organization
Organization Name:DONALD M. JACOBSON, MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-930-6522
Mailing Address - Street 1:3701 DURAND AVE STE 325
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4480
Mailing Address - Country:US
Mailing Address - Phone:262-598-9030
Mailing Address - Fax:262-598-9032
Practice Address - Street 1:3701 DURAND AVE STE 325
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-4480
Practice Address - Country:US
Practice Address - Phone:262-598-9030
Practice Address - Fax:262-598-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33729174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIA74083Medicare UPIN