Provider Demographics
NPI:1407879554
Name:JACOBSON, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DO
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 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-272-4451
Mailing Address - Fax:717-272-4532
Practice Address - Street 1:4TH & WILLOW STREET
Practice Address - Street 2:HYMAN CAPLAN PAVILION
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-0300
Practice Address - Country:US
Practice Address - Phone:717-272-4451
Practice Address - Fax:717-272-4532
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005977L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01230300Medicaid
JA129827Medicare ID - Type Unspecified
PA01230300Medicaid