Provider Demographics
NPI:1851877930
Name:JACOBSON, BRIAN JAY (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAY
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:72650 FRED WARING DR STE 204
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-5009
Mailing Address - Country:US
Mailing Address - Phone:760-760-3434
Mailing Address - Fax:760-760-4345
Practice Address - Street 1:72650 FRED WARING DR STE 204
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-5009
Practice Address - Country:US
Practice Address - Phone:760-760-3434
Practice Address - Fax:760-760-4345
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8350108-1206363A00000X
CA57284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant