Provider Demographics
NPI:1386674950
Name:JACOBSEN, SCOTT (DPM)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:720 FLORSHEIM DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3757
Practice Address - Country:US
Practice Address - Phone:847-247-4000
Practice Address - Fax:847-234-2090
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005031213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213648Medicare PIN
IL016005031Medicaid
IL4302510001Medicare NSC
ILP00347050OtherRAILROAD MEDICARE
ILU90921Medicare UPIN
IL04932511OtherBLUE CROSS BLUE SHIELD