Provider Demographics
NPI:1811105745
Name:JACOBSEN, GREG ROBERT (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:ROBERT
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 1:383 S 300 E
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3620
Mailing Address - Country:US
Mailing Address - Phone:435-628-2826
Mailing Address - Fax:
Practice Address - Street 1:383 S 300 E
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3620
Practice Address - Country:US
Practice Address - Phone:435-628-2826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7153621-1205207N00000X
PAMT187813207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology