Provider Demographics
NPI:1134881469
Name:JACOBSON, JAMES R
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MDG
Mailing Address - Street 2:OPC 80 BOX 5217
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368-5217
Mailing Address - Country:US
Mailing Address - Phone:315-630-4817
Mailing Address - Fax:
Practice Address - Street 1:18 MDG
Practice Address - Street 2:OPC 80 BOX 5217
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5217
Practice Address - Country:US
Practice Address - Phone:315-630-4817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical