Provider Demographics
NPI:1770099814
Name:JACOBSON, JEDIDIAH ANDREW (CPO)
Entity type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:ANDREW
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 W CHAPMAN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2331
Mailing Address - Country:US
Mailing Address - Phone:714-602-6436
Mailing Address - Fax:
Practice Address - Street 1:2140 W CHAPMAN AVE STE 103
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2331
Practice Address - Country:US
Practice Address - Phone:714-602-6436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO03265224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist