Provider Demographics
NPI:1982887253
Name:LOIS J JACOBS MD PHD S C
Entity Type:Organization
Organization Name:LOIS J JACOBS MD PHD S C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:920-231-5313
Mailing Address - Street 1:1510 ARBORETUM DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2790
Mailing Address - Country:US
Mailing Address - Phone:920-231-5313
Mailing Address - Fax:920-231-5348
Practice Address - Street 1:1510 ARBORETUM DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2790
Practice Address - Country:US
Practice Address - Phone:920-231-5313
Practice Address - Fax:920-231-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI30302261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31609600Medicaid
WIE47582Medicare UPIN