Provider Demographics
NPI:1043617434
Name:JACOBSON, ERIC K (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:K
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4560
Practice Address - Street 1:390 RIVER STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2226
Practice Address - Country:US
Practice Address - Phone:802-886-4500
Practice Address - Fax:802-886-4560
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09021363A00000X
VT055.0031321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353455401Medicaid
TX353445402OtherCSHCN
TX469728YK00Medicare PIN