Provider Demographics
NPI:1659394484
Name:JACOBSON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:505 BAY AVE
Mailing Address - Street 2:BAYSIDE COMMONS
Mailing Address - City:SOMMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244
Mailing Address - Country:US
Mailing Address - Phone:609-927-4235
Mailing Address - Fax:609-927-5590
Practice Address - Street 1:505 BAY AVE
Practice Address - Street 2:BAYSIDE COMMONS
Practice Address - City:SOMMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244
Practice Address - Country:US
Practice Address - Phone:609-927-4235
Practice Address - Fax:609-927-5590
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB03043900208000000X
PAOS-003415-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2261308Medicaid
658266Medicare ID - Type Unspecified
C55579Medicare UPIN