Provider Demographics
NPI:1952443673
Name:JACOBSON, RICHARD SAMUEL (M,D,)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:SAMUEL
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:M,D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11591 YARMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2102
Mailing Address - Country:US
Mailing Address - Phone:818-366-7700
Mailing Address - Fax:
Practice Address - Street 1:10515 BALBOA BL.
Practice Address - Street 2:SUITE 250
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344
Practice Address - Country:US
Practice Address - Phone:818-831-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG155882080P0006X, 2080P0008X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G155880Medicaid
CAG15588OtherSTATE LICENSE NUM
CAG15588OtherSTATE LICENSE NUM