Provider Demographics
NPI:1134233273
Name:JON S JACOBSON MD
Entity type:Organization
Organization Name:JON S JACOBSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:S
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-974-5530
Mailing Address - Street 1:PO BOX 4387
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-2620
Mailing Address - Country:US
Mailing Address - Phone:928-634-0665
Mailing Address - Fax:
Practice Address - Street 1:13943 N 91ST AVE
Practice Address - Street 2:BLDG G
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-3687
Practice Address - Country:US
Practice Address - Phone:623-974-5530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14654207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ=========Medicare PIN