Provider Demographics
NPI:1225501547
Name:JACOBSON, WILLIAM L
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5633 BARHAM CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-5721
Mailing Address - Country:US
Mailing Address - Phone:919-538-3658
Mailing Address - Fax:
Practice Address - Street 1:2500 WARREN CARROLL DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27695-5721
Practice Address - Country:US
Practice Address - Phone:919-515-2111
Practice Address - Fax:919-515-0728
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-42952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer