Provider Demographics
NPI:1659837755
Name:YACOBSON, ILYA (MS, LAC)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:YACOBSON
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ALPINE TER
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3112
Mailing Address - Country:US
Mailing Address - Phone:510-207-3553
Mailing Address - Fax:
Practice Address - Street 1:101 ALPINE TER
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3112
Practice Address - Country:US
Practice Address - Phone:510-207-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11942171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist