Provider Demographics
NPI:1194818898
Name:JACOBSON, JORDAN IRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:IRA
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E 106TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4005
Mailing Address - Country:US
Mailing Address - Phone:212-348-0020
Mailing Address - Fax:646-219-2039
Practice Address - Street 1:231 E 106TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4005
Practice Address - Country:US
Practice Address - Phone:212-348-0020
Practice Address - Fax:646-219-2039
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0514871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051487OtherDENTAL LICENSE