Provider Demographics
NPI:1568448579
Name:JACOBSON, PAUL KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:KENNETH
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5441
Mailing Address - Country:US
Mailing Address - Phone:507-333-3207
Mailing Address - Fax:507-333-3302
Practice Address - Street 1:924 1ST ST NE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5441
Practice Address - Country:US
Practice Address - Phone:507-333-3207
Practice Address - Fax:507-333-3302
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080169214OtherMEDICARE RAILROAD
MN958767500Medicaid
MN080169214OtherMEDICARE RAILROAD