Provider Demographics
NPI:1437357860
Name:JACOBSEN, JARED W (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:W
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 PORT BARMOUTH PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1122 E LINCOLN AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1907
Practice Address - Country:US
Practice Address - Phone:714-637-6700
Practice Address - Fax:714-637-5889
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA455781223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics