Provider Demographics
NPI:1346238847
Name:JACOBSON, DENNIS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RICHARD
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 1:1805 HENNEPIN AVE N
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-1416
Mailing Address - Country:US
Mailing Address - Phone:320-864-3121
Mailing Address - Fax:320-864-7887
Practice Address - Street 1:1805 HENNEPIN AVE N
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-1416
Practice Address - Country:US
Practice Address - Phone:320-864-3121
Practice Address - Fax:320-864-7887
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75663Medicare UPIN