Provider Demographics
NPI:1629010665
Name:JACOBSON, EVAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:L
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 1:3801 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2758
Mailing Address - Country:US
Mailing Address - Phone:561-815-9791
Mailing Address - Fax:561-972-7283
Practice Address - Street 1:3801 PGA BLVD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2758
Practice Address - Country:US
Practice Address - Phone:561-815-9791
Practice Address - Fax:561-972-7283
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1502652084P0800X
VA01012365702084P0800X
MDD00618392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDI41515Medicare UPIN
MDS582M315Medicare PIN