Provider Demographics
NPI:1285647669
Name:JACOBSON, TIMOTHY DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DENNIS
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3032 NE 17TH AVE
Mailing Address - Street 2:OREGON HEALTH AND SCIENCE UNIVERSITY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3352
Mailing Address - Country:US
Mailing Address - Phone:503-284-2801
Mailing Address - Fax:503-494-8550
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:503-494-8550
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286513Medicaid
OR113629Medicare PIN
OR286513Medicaid