Provider Demographics
NPI:1376578120
Name:JACOBSON, PHILLIP ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ALBERT
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 1:8 W MONROE ST APT 2101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2453
Mailing Address - Country:US
Mailing Address - Phone:866-710-1018
Mailing Address - Fax:
Practice Address - Street 1:8 W MONROE ST APT 2101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603-2453
Practice Address - Country:US
Practice Address - Phone:866-710-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-084957208000000X, 2080P0203X
IL036084957208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC37499Medicare UPIN