Provider Demographics
NPI:1609937432
Name:JACOBSON, JEFFREY RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RANDALL
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 1:909 SOUTH WOLCOTT AVENUE
Mailing Address - Street 2:3141 COMRB
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3725
Mailing Address - Country:US
Mailing Address - Phone:312-996-8039
Mailing Address - Fax:312-996-4665
Practice Address - Street 1:909 SOUTH WOLCOTT AVENUE
Practice Address - Street 2:3141 COMRB
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3725
Practice Address - Country:US
Practice Address - Phone:312-996-8039
Practice Address - Fax:312-996-4665
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114116207RP1001X
IL036.114116207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114116Medicaid
IL036114116Medicaid
K19990Medicare ID - Type Unspecified