Provider Demographics
NPI:1417933110
Name:JAKOBSEN, LARS JAKOB (MD)
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:JAKOB
Last Name:JAKOBSEN
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 1:9708 MAGELLAN DR
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-9736
Mailing Address - Country:US
Mailing Address - Phone:530-652-3102
Mailing Address - Fax:
Practice Address - Street 1:3111 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2456
Practice Address - Country:US
Practice Address - Phone:530-885-5618
Practice Address - Fax:530-889-0636
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG077316207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773160Medicaid
CA00G773160Medicare ID - Type Unspecified
CA00G773160Medicaid