Provider Demographics
NPI:1447432125
Name:JACOBSEN, CARL J SR (CERTIFIED OPTICIAN A)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:J
Last Name:JACOBSEN
Suffix:SR
Gender:M
Credentials:CERTIFIED OPTICIAN A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2710
Mailing Address - Country:US
Mailing Address - Phone:215-884-7715
Mailing Address - Fax:215-884-7920
Practice Address - Street 1:715 WEST AVE
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2710
Practice Address - Country:US
Practice Address - Phone:215-884-7715
Practice Address - Fax:215-884-7715
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0743370001OtherPROVIDER NUMBER