Provider Demographics
NPI:1780753822
Name:JACOBSON, JON R (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 N GREEN MOUNT RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2083
Mailing Address - Country:US
Mailing Address - Phone:618-628-8440
Mailing Address - Fax:
Practice Address - Street 1:1512 N GREEN MOUNT RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2083
Practice Address - Country:US
Practice Address - Phone:618-628-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361495302083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty