Provider Demographics
NPI:1558352096
Name:JACOBSEN, WALTER (DPM)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4401
Mailing Address - Country:US
Mailing Address - Phone:773-561-7627
Mailing Address - Fax:773-561-1111
Practice Address - Street 1:1111 W BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4401
Practice Address - Country:US
Practice Address - Phone:773-561-7627
Practice Address - Fax:773-561-1111
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist