Provider Demographics
NPI:1477500288
Name:JACOBSON, RICHARD WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WESLEY
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:ONE ST. MARY PLACE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-681-4222
Mailing Address - Fax:318-681-6114
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-4222
Practice Address - Fax:318-681-6114
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15048R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1160997Medicaid
LA1160997Medicaid
LA4F787C639Medicare ID - Type Unspecified