Provider Demographics
NPI:1821092891
Name:JACOBSEN, ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 W SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-8809
Mailing Address - Country:US
Mailing Address - Phone:217-367-7546
Mailing Address - Fax:217-367-2240
Practice Address - Street 1:407 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-8809
Practice Address - Country:US
Practice Address - Phone:217-367-7546
Practice Address - Fax:217-367-2240
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099003Medicaid
IL036099003Medicaid
IL556240Medicare ID - Type Unspecified