Provider Demographics
NPI:1376592733
Name:JACOBSON, GRETCHEN H (MD)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:H
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N ROSE AVE
Mailing Address - Street 2:#250
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030
Mailing Address - Country:US
Mailing Address - Phone:805-983-1700
Mailing Address - Fax:805-983-7144
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:#250
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030
Practice Address - Country:US
Practice Address - Phone:805-983-1700
Practice Address - Fax:805-983-7144
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63450207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG634500Medicaid
CAOOG634500Medicaid
CAG63450Medicare PIN
A17190Medicare UPIN