Provider Demographics
NPI:1750835690
Name:JACOBSON PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:JACOBSON PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-303-2100
Mailing Address - Street 1:2518 SUPERIOR DRIVE NW
Mailing Address - Street 2:STE 104
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902
Mailing Address - Country:US
Mailing Address - Phone:952-303-2100
Mailing Address - Fax:
Practice Address - Street 1:2518 SUPERIOR DR NW
Practice Address - Street 2:STE 104
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1988
Practice Address - Country:US
Practice Address - Phone:952-303-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN053825600Medicaid
MN1104899830OtherNPI
MN053825600Medicaid