Provider Demographics
NPI:1679772164
Name:JACOBSOHN, KENNETH MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MITCHELL
Last Name:JACOBSOHN
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF UROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-0805
Mailing Address - Fax:414-805-0771
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF UROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-0805
Practice Address - Fax:414-805-0771
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98651208800000X
WI51655-020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679772164Medicaid
WI680860584Medicare PIN
WI0013 73035Medicare PIN
WI736011570Medicare PIN
WI0010 68115Medicare PIN