Provider Demographics
NPI:1659465607
Name:JACOBSON, JULIENNE RAQUEL (MD)
Entity Type:Individual
Prefix:
First Name:JULIENNE
Middle Name:RAQUEL
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7901
Mailing Address - Country:US
Mailing Address - Phone:323-669-2337
Mailing Address - Fax:323-644-8488
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 82
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2471
Practice Address - Fax:323-667-2019
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA683052084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A683050 N66OtherCAL OPTIMA'
CA00A683050Medicaid
CAH73982Medicare UPIN
CAWA68305AMedicare ID - Type Unspecified