Provider Demographics
NPI:1750494449
Name:LEE R JACOBSON OD SC
Entity Type:Organization
Organization Name:LEE R JACOBSON OD SC
Other - Org Name:JACOBSON ADVANCED EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:JACOBSON
Authorized Official - Last Name:TURCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DD
Authorized Official - Phone:715-822-2091
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:1357 SECOND AVE
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829
Mailing Address - Country:US
Mailing Address - Phone:715-822-2091
Mailing Address - Fax:715-822-3624
Practice Address - Street 1:1357 SECOND AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829
Practice Address - Country:US
Practice Address - Phone:715-822-2091
Practice Address - Fax:715-822-3624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDB1413OtherRR PTAN DB1413
WI38728100Medicaid
WI0321190001Medicare NSC
WIDB1413OtherRR PTAN DB1413