Provider Demographics
NPI:1013959188
Name:JACOBSON, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:JACOBSON
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3400
Mailing Address - Country:US
Mailing Address - Phone:970-224-9102
Mailing Address - Fax:970-224-9112
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3400
Practice Address - Country:US
Practice Address - Phone:970-224-9102
Practice Address - Fax:970-224-9112
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-08-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110002152363AM0700X
COPA.0004358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19730136Medicaid
VAQ56651Medicare UPIN
CO19730136Medicaid