Provider Demographics
NPI:1376588210
Name:JACOBSEN, ERIK (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:JACOBSEN
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 2018
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78768-2018
Mailing Address - Country:US
Mailing Address - Phone:512-305-7010
Mailing Address - Fax:
Practice Address - Street 1:2600 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2372
Practice Address - Country:US
Practice Address - Phone:903-614-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F6414Medicare PIN
TX8C8814Medicare ID - Type Unspecified
H74862Medicare UPIN