Provider Demographics
NPI:1114501723
Name:JACOBSON, AMBER ROSE
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:ROSE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 SOUTH STATE STREET
Mailing Address - Street 2:MAILCODE: 3007
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901
Mailing Address - Country:US
Mailing Address - Phone:302-744-6999
Mailing Address - Fax:
Practice Address - Street 1:640 SOUTH STATE STREET
Practice Address - Street 2:3007
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-744-6999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-0018194208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery