Provider Demographics
NPI:1962456772
Name:JACOBSON, ELLEN R (MD)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-851-2018
Practice Address - Street 1:4515 HARDING RD
Practice Address - Street 2:SUITE 310
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205
Practice Address - Country:US
Practice Address - Phone:615-279-5656
Practice Address - Fax:615-279-5602
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019503174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6049042OtherBCBS
TNE98089Medicare UPIN
TN6049042OtherBCBS