Provider Demographics
NPI:1801060561
Name:W JACOBSEN DPM PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:W JACOBSEN DPM PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-561-7626
Mailing Address - Street 1:1126 W BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4410
Mailing Address - Country:US
Mailing Address - Phone:773-561-7626
Mailing Address - Fax:773-561-1111
Practice Address - Street 1:1126 W BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4410
Practice Address - Country:US
Practice Address - Phone:773-561-7626
Practice Address - Fax:773-561-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004485213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U 05238Medicare UPIN