Provider Demographics
NPI:1366677759
Name:JACOBSON, TREVOR DEAN (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:DEAN
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-0069
Mailing Address - Country:US
Mailing Address - Phone:208-847-1110
Mailing Address - Fax:208-847-0228
Practice Address - Street 1:166 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-4959
Practice Address - Country:US
Practice Address - Phone:208-847-1110
Practice Address - Fax:208-847-0228
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12665207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine