Provider Demographics
NPI:1194839654
Name:JACOBSON, SANDE R (DC)
Entity Type:Individual
Prefix:DR
First Name:SANDE
Middle Name:R
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 1:1405 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4413
Mailing Address - Country:US
Mailing Address - Phone:215-801-5457
Mailing Address - Fax:
Practice Address - Street 1:9500 NORTHEAST AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-673-9500
Practice Address - Fax:215-671-1112
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004909L111N00000X
PADC4909C111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA143581PEVMedicare ID - Type Unspecified