Provider Demographics
NPI:1205947546
Name:JACOBY, LYNN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:MARIE
Last Name:JACOBY
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 1:559 VINCENT ST
Mailing Address - Street 2:21 MDG/BDAA PEDIATRICS
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1541
Mailing Address - Country:US
Mailing Address - Phone:719-556-1145
Mailing Address - Fax:866-867-7926
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:21 MDG/BDAA PEDIATRICS
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33770207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I35163Medicare UPIN