Provider Demographics
NPI:1629050323
Name:JACOBSON, JACK MERLIN (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MERLIN
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 1:511 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4007
Mailing Address - Country:US
Mailing Address - Phone:512-244-0161
Mailing Address - Fax:512-244-7814
Practice Address - Street 1:511 OAKWOOD BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4007
Practice Address - Country:US
Practice Address - Phone:512-244-0161
Practice Address - Fax:512-244-7814
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC6380208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX834575Medicare ID - Type Unspecified
TXA33023Medicare UPIN