Provider Demographics
NPI:1689626947
Name:JACOBSON, JEFFREY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JEFFREY
Other - Middle Name:LEE
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2921 ERIE BLVD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7665
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:1400 OAKLAWN AVE
Practice Address - Street 2:OPTOMETRIC PROVIDERS OF RHODE ISLAND, INC
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-2643
Practice Address - Country:US
Practice Address - Phone:401-463-6696
Practice Address - Fax:401-463-5913
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T53574Medicare UPIN