Provider Demographics
NPI:1689654022
Name:JACOBSON, HEIDI L (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:LEVERENZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:310 E 6TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5943
Mailing Address - Country:US
Mailing Address - Phone:458-225-2123
Mailing Address - Fax:541-482-2446
Practice Address - Street 1:310 E 6TH ST
Practice Address - Street 2:#202
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-5933
Practice Address - Country:US
Practice Address - Phone:541-245-2787
Practice Address - Fax:541-899-3243
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005591010OtherREGENCE BLUE CROSS
OR011895Medicaid
E57928Medicare UPIN
OR011895Medicaid