Provider Demographics
NPI:1174648059
Name:JACOBSEN, ALMA (OD)
Entity Type:Individual
Prefix:DR
First Name:ALMA
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:ALMA
Other - Middle Name:
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:21 TYNDALE RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-1354
Mailing Address - Country:US
Mailing Address - Phone:609-838-0795
Mailing Address - Fax:
Practice Address - Street 1:400 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:N BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-5100
Practice Address - Country:US
Practice Address - Phone:732-821-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00583600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0015725Medicaid
NJ0015725Medicaid
NJ071252Medicare ID - Type Unspecified