Provider Demographics
NPI:1669576690
Name:JACOBSON, DANIEL WADE (RPH)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WADE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4251
Mailing Address - Country:US
Mailing Address - Phone:406-868-7013
Mailing Address - Fax:
Practice Address - Street 1:2800 11TH AVE S STE 10
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5263
Practice Address - Country:US
Practice Address - Phone:406-727-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPHA-PHA-LIC-3808183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist