Provider Demographics
NPI:1821298407
Name:BERTRAM JACOBSON
Entity Type:Organization
Organization Name:BERTRAM JACOBSON
Other - Org Name:JACOBSON CHIROPRACTIC HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-673-9500
Mailing Address - Street 1:126 DELIA LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3406
Mailing Address - Country:US
Mailing Address - Phone:215-673-9500
Mailing Address - Fax:215-671-1112
Practice Address - Street 1:126 DELIA LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3406
Practice Address - Country:US
Practice Address - Phone:215-673-9500
Practice Address - Fax:215-671-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2011-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA042654Medicare UPIN