Provider Demographics
NPI:1679527444
Name:JACOBSEN, DONALD SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:SCOTT
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 JOHNSTON ST
Mailing Address - Street 2:SUITE 2314
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-984-2410
Mailing Address - Fax:337-984-2416
Practice Address - Street 1:5725 JOHNSTON ST
Practice Address - Street 2:SUITE 2314
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-984-2410
Practice Address - Fax:337-984-2416
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA912360T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T69517Medicare UPIN
LA47916C690Medicare ID - Type Unspecified