Provider Demographics
NPI:1770590168
Name:JACOBSON, JEROME R (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6101 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6101 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3875
Practice Address - Country:US
Practice Address - Phone:386-326-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059609208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370150600Medicaid
FL14942Medicare ID - Type Unspecified
FL370150600Medicaid