Provider Demographics
NPI:1669493847
Name:JAKOBSON, IVAR
Entity Type:Individual
Prefix:
First Name:IVAR
Middle Name:
Last Name:JAKOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:OSAGE
Mailing Address - State:IA
Mailing Address - Zip Code:50461-1716
Mailing Address - Country:US
Mailing Address - Phone:641-732-3660
Mailing Address - Fax:
Practice Address - Street 1:635 MAIN ST
Practice Address - Street 2:
Practice Address - City:OSAGE
Practice Address - State:IA
Practice Address - Zip Code:50461-1307
Practice Address - Country:US
Practice Address - Phone:641-732-5452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16454183500000X
IA521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0033993Medicaid
IANABP 1614672OtherNABP