Provider Demographics
NPI:1558320044
Name:JACOBSON, GERI NEWMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GERI
Middle Name:NEWMAN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GERI
Other - Middle Name:S
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR #1300
Mailing Address - Street 2:CENTRA CARE CLINIC WOMEN'S & CHILDRENS
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3610
Mailing Address - Fax:505-722-1268
Practice Address - Street 1:1900 CENTRACARE CIR #1300
Practice Address - Street 2:CENTRA CARE CLINIC WOMEN'S & CHILDRENS
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3610
Practice Address - Fax:505-722-1268
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39068208000000X
MN53579208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ477225Medicaid
NM000Z9493Medicaid
370004372Medicare PIN