Provider Demographics
NPI:1336121243
Name:JACOBSON, KEITH LAURENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LAURENCE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8101 E LOWRY BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-7196
Mailing Address - Country:US
Mailing Address - Phone:303-344-9090
Mailing Address - Fax:720-859-4017
Practice Address - Street 1:8101 E LOWRY BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80230-7196
Practice Address - Country:US
Practice Address - Phone:303-344-9090
Practice Address - Fax:720-859-4017
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO699213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82687579Medicaid
TXU82402Medicare UPIN