Provider Demographics
NPI:1922073766
Name:JACOBSON, LISA WAITE (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:WAITE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8872 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8481
Mailing Address - Country:US
Mailing Address - Phone:231-779-6260
Mailing Address - Fax:231-779-6264
Practice Address - Street 1:8872 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8481
Practice Address - Country:US
Practice Address - Phone:231-779-6260
Practice Address - Fax:231-779-6264
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013549207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4420424Medicaid
MI4420424Medicaid