Provider Demographics
NPI:1689234155
Name:JACOBSON, CHRISTIAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:MICHAEL
Last Name:JACOBSON
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 1:173 PLYMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1477
Mailing Address - Country:US
Mailing Address - Phone:518-522-2273
Mailing Address - Fax:
Practice Address - Street 1:2351 E 22ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3111
Practice Address - Country:US
Practice Address - Phone:216-861-6200
Practice Address - Fax:216-363-7490
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.145713207P00000X
OH57.248343390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine