Provider Demographics
NPI:1790771384
Name:JACOBSEN, PAULA I (OD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:I
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 CROSSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:SILVIS
Mailing Address - State:IL
Mailing Address - Zip Code:61282-1651
Mailing Address - Country:US
Mailing Address - Phone:309-796-1444
Mailing Address - Fax:309-796-1496
Practice Address - Street 1:704 CROSSTOWN AVE
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-1651
Practice Address - Country:US
Practice Address - Phone:309-796-1444
Practice Address - Fax:309-796-1496
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008226152W00000X
IA1896152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08184019OtherBLUE CROSS BLUE SHIELD OF IL
ILT90775Medicare UPIN
IL3915650001Medicare NSC
IL410000115Medicare PIN
IL08184019OtherBLUE CROSS BLUE SHIELD OF IL