Provider Demographics
NPI:1649292095
Name:JACOBSEN, CHAD THOMAS (MD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:THOMAS
Last Name:JACOBSEN
Suffix:
Gender:M
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-02008208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2232266Medicaid
OH2426331OtherAETNA
OH733967OtherBUCKEYE
OH000000183485OtherANTHEM
OH000000217233OtherUNISON
OH2232266OtherBCMH
OH363661OtherWELLCARE
NC5910863Medicaid
OH000000526032OtherANTHEM
SCN02008Medicaid
NCNC8783AMedicare PIN
OH000000526032OtherANTHEM
NC5910863Medicaid
OHJA4041631Medicare ID - Type Unspecified
NC2023265Medicare PIN