Provider Demographics
NPI:1306850961
Name:JACOBSON, KEVIN E (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:E
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W KNAPP ST
Mailing Address - Street 2:STE 3
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868
Mailing Address - Country:US
Mailing Address - Phone:715-234-3113
Mailing Address - Fax:715-234-2339
Practice Address - Street 1:1801 W KNAPP ST
Practice Address - Street 2:STE 3
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868
Practice Address - Country:US
Practice Address - Phone:715-234-3113
Practice Address - Fax:715-234-2339
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38527700Medicaid
T62294Medicare UPIN
WI38527700Medicaid