Provider Demographics
NPI:1083753776
Name:GRETCHEN H. JACOBSON, MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:GRETCHEN H. JACOBSON, MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-983-1700
Mailing Address - Street 1:1700 N ROSE AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-7626
Mailing Address - Country:US
Mailing Address - Phone:805-983-1700
Mailing Address - Fax:805-983-7144
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:#250
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3790
Practice Address - Country:US
Practice Address - Phone:805-983-1700
Practice Address - Fax:805-983-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63450207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G634500Medicaid
CA00G634500Medicaid
CAG63450Medicare PIN
CAW22239Medicare PIN