Provider Demographics
NPI:1184971517
Name:JACOBSON, TORAN (NA)
Entity type:Individual
Prefix:MR
First Name:TORAN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 JACKSON PL
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4208
Mailing Address - Country:US
Mailing Address - Phone:286-360-9272
Mailing Address - Fax:
Practice Address - Street 1:315 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4209
Practice Address - Country:US
Practice Address - Phone:286-360-9272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Y00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health Information