Provider Demographics
NPI:1760492656
Name:JACOBSON, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W A ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-5065
Mailing Address - Country:US
Mailing Address - Phone:208-883-2828
Mailing Address - Fax:208-882-2179
Practice Address - Street 1:2500 W A ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-5065
Practice Address - Country:US
Practice Address - Phone:208-883-2828
Practice Address - Fax:208-882-2179
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6567207X00000X
WA31851207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0102784OtherDEPT OF LABOR
ID002743901Medicaid
WA1092733Medicaid
A89835Medicare UPIN
0343160002Medicare NSC
WA319300002Medicare PIN
ID200019624Medicare ID - Type UnspecifiedRAILROAD MEDICARE
A89835Medicare UPIN
0343160002Medicare NSC