Provider Demographics
NPI:1528183985
Name:JACOBS, KAREN (OTR)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:JACOBS GOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:635 COMMONWEALTH AVE
Mailing Address - Street 2:BU
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-1605
Mailing Address - Country:US
Mailing Address - Phone:617-353-7516
Mailing Address - Fax:617-353-2926
Practice Address - Street 1:635 COMMONWEALTH AVE
Practice Address - Street 2:BU
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-1605
Practice Address - Country:US
Practice Address - Phone:617-353-7516
Practice Address - Fax:617-353-2926
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAOT0050OtherBCBS
MAY69279PMedicare ID - Type UnspecifiedMEDICARE B