Provider Demographics
NPI:1932594256
Name:PAUL E JACOBSEN
Entity Type:Organization
Organization Name:PAUL E JACOBSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-945-5477
Mailing Address - Street 1:17101 NE 19TH AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3159
Mailing Address - Country:US
Mailing Address - Phone:305-945-5477
Mailing Address - Fax:
Practice Address - Street 1:17101 NE 19TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3159
Practice Address - Country:US
Practice Address - Phone:305-945-5477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty