Provider Demographics
NPI:1629012414
Name:JACOBSON, SCOTT M
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 APPLETON DR
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-3210
Mailing Address - Country:US
Mailing Address - Phone:724-527-1975
Mailing Address - Fax:724-527-6589
Practice Address - Street 1:532 W PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2239
Practice Address - Country:US
Practice Address - Phone:724-527-1975
Practice Address - Fax:724-527-6589
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS011956207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001869316Medicaid
PA174160Medicare PIN
PAH21938Medicare UPIN