Provider Demographics
NPI:1194000232
Name:JACOBSON, DAVID RICHARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NEW PINERY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9221
Mailing Address - Country:US
Mailing Address - Phone:608-742-5727
Mailing Address - Fax:608-745-4217
Practice Address - Street 1:2700 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9221
Practice Address - Country:US
Practice Address - Phone:608-742-5727
Practice Address - Fax:608-745-4217
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14126-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist