Provider Demographics
NPI:1386644284
Name:JACOBSON, LEE R (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-7211
Mailing Address - Country:US
Mailing Address - Phone:715-822-2091
Mailing Address - Fax:715-822-3624
Practice Address - Street 1:1357 2ND AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-7211
Practice Address - Country:US
Practice Address - Phone:715-822-2091
Practice Address - Fax:715-822-3624
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1298152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38541900Medicaid
WI410011362OtherRR-PTAN 410011362
WI410040506OtherRR-PTAN 410040506
WI410040506OtherRR-PTAN 410040506
WI000147430Medicare PIN
WI38541900Medicaid
WI0321190002Medicare NSC
WI000147425Medicare PIN