Provider Demographics
NPI:1013968858
Name:JACOBSON, RICHARD DAVID (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVID
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MARYLAND FARMS STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:615-345-5400
Mailing Address - Fax:888-468-6603
Practice Address - Street 1:4228 BROOKFIELD DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:615-345-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312162084N0400X
FLME1278472084N0400X, 2084N0402X
NC013892084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915702Medicaid
FLME127847OtherSTATE LICENSE
E10063Medicare UPIN
NC5915702Medicaid