Provider Demographics
NPI:1790833549
Name:JACOBSON, MARY (OD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:UY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1945 N ROYAL BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-4572
Mailing Address - Country:US
Mailing Address - Phone:312-320-0333
Mailing Address - Fax:
Practice Address - Street 1:307 GOLF MILL CTR
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1217
Practice Address - Country:US
Practice Address - Phone:847-803-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46008491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU79887Medicare UPIN
ILL77664Medicare ID - Type Unspecified