Provider Demographics
NPI:1760443659
Name:JACOBSON, DAVID JR (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:JACOBSON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7381 WILLOW RUN DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-3529
Mailing Address - Country:US
Mailing Address - Phone:440-413-0877
Mailing Address - Fax:
Practice Address - Street 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-953-6203
Practice Address - Fax:440-953-6202
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022384-1363A00000X
OH50000362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
JAPA11676Medicare ID - Type Unspecified