Provider Demographics
NPI:1861446874
Name:JACOBSON, JEFFREY MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
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 1:411 CANISTEO ST
Mailing Address - Street 2:
Mailing Address - City:HORNELL
Mailing Address - State:NY
Mailing Address - Zip Code:14843-2104
Mailing Address - Country:US
Mailing Address - Phone:607-324-8255
Mailing Address - Fax:607-324-8774
Practice Address - Street 1:411 CANISTEO ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-2104
Practice Address - Country:US
Practice Address - Phone:607-324-8255
Practice Address - Fax:607-324-8774
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168781-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000929320001OtherHEALTHNOW
NY198781OtherGREAT WEST LICENSE #
NY01718249Medicaid
NY10820256OtherCAQH
NY178209FFOtherPREFERRED CARE
NY7226804OtherAETNA
NY10820256OtherCAQH
NY01718249Medicaid