Provider Demographics
NPI:1659349389
Name:JACOBSON, WALTER ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:ERIC
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 1:5699 KANAN RD
Mailing Address - Street 2:SUITE 433
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-3358
Mailing Address - Country:US
Mailing Address - Phone:818-885-8500
Mailing Address - Fax:818-865-2124
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:IFL TOWER, 4TH FLOOR
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4105
Practice Address - Country:US
Practice Address - Phone:818-885-8500
Practice Address - Fax:818-865-2124
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA610162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG38699Medicare UPIN