Provider Demographics
NPI:1922042340
Name:JACOBSEN, RYAN CODY (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:CODY
Last Name:JACOBSEN
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 1:14517 W 92ND ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-3060
Mailing Address - Country:US
Mailing Address - Phone:913-599-2656
Mailing Address - Fax:
Practice Address - Street 1:2411 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2741
Practice Address - Country:US
Practice Address - Phone:816-235-6626
Practice Address - Fax:816-235-6629
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2007027058207P00000X
KS04-36348207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program