Provider Demographics
NPI:1023450145
Name:JACOBSEN, ELIZABETH MARIE (DPM)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W 35TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-5820
Mailing Address - Country:US
Mailing Address - Phone:563-391-2889
Mailing Address - Fax:563-391-2988
Practice Address - Street 1:430 W 35TH ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5820
Practice Address - Country:US
Practice Address - Phone:563-391-2889
Practice Address - Fax:563-391-2988
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135.000811213ES0103X
IA085216213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA085216OtherPROFESSIONAL LICENSE
IL135.000811OtherPROFESSIONAL LICENSE