Provider Demographics
NPI:1144337858
Name:JACOBSON, BRET JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:JOHN
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 N 2200 E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-5304
Mailing Address - Country:US
Mailing Address - Phone:435-512-8202
Mailing Address - Fax:
Practice Address - Street 1:990 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0001
Practice Address - Country:US
Practice Address - Phone:208-282-3407
Practice Address - Fax:208-282-6150
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT355300-1701183500000X
IDP7371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist