Provider Demographics
NPI:1821131780
Name:JACOBSON, PAUL ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ALLEN
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 1:4044 W LAKE MARY BLVD
Mailing Address - Street 2:#410
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2012
Mailing Address - Country:US
Mailing Address - Phone:407-718-8000
Mailing Address - Fax:
Practice Address - Street 1:4044 W LAKE MARY BLVD
Practice Address - Street 2:#410
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2012
Practice Address - Country:US
Practice Address - Phone:407-718-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL387372084P0800X
FLME387372084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040565500Medicaid
FLD65216Medicare UPIN
FL59943Medicare ID - Type Unspecified