Provider Demographics
NPI:1467149633
Name:JACOBSON, SPENCER (DMD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4537 S MOSSY SPRINGS LN
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6999
Mailing Address - Country:US
Mailing Address - Phone:435-851-4197
Mailing Address - Fax:
Practice Address - Street 1:303 N KEENE ST STE 202
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8052
Practice Address - Country:US
Practice Address - Phone:573-777-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program