Provider Demographics
NPI:1194034314
Name:JACOBSON, AMMON (DC)
Entity Type:Individual
Prefix:DR
First Name:AMMON
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-1100
Mailing Address - Country:US
Mailing Address - Phone:719-390-5404
Mailing Address - Fax:
Practice Address - Street 1:1825 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911
Practice Address - Country:US
Practice Address - Phone:719-390-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0007920111N00000X
IL038011781111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12584507OtherCAQH