Provider Demographics
NPI:1083684633
Name:JACOBSON, KRIS N (MD)
Entity Type:Individual
Prefix:MR
First Name:KRIS
Middle Name:N
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 1:1917 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-770-2031
Mailing Address - Fax:
Practice Address - Street 1:2860 CREEKSIDE CIRCLE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-779-8367
Practice Address - Fax:541-779-7471
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16535207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAUSA242450Medicaid
OR008610Medicaid
E68715Medicare UPIN
000WRGTDMedicare ID - Type Unspecified