Provider Demographics
NPI:1457456089
Name:JACOBSON, TERRY A (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:A
Last Name:JACOBSON
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 1:49 JESSE HILL JR DR SE
Mailing Address - Street 2:EMORY FACULTY OFFICE BUILDING
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3049
Mailing Address - Country:US
Mailing Address - Phone:404-778-1625
Mailing Address - Fax:404-778-1602
Practice Address - Street 1:49 JESSE HILL JR DR SE
Practice Address - Street 2:EMORY FACULTY OFFICE BUILDING
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3049
Practice Address - Country:US
Practice Address - Phone:404-778-1625
Practice Address - Fax:404-778-1602
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA037575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00568367AMedicaid
GA00568367AMedicaid
GA11BDGMQMedicare ID - Type Unspecified