Provider Demographics
NPI:1174899041
Name:MARTIN JACOBSON, D.C., P.A.
Entity type:Organization
Organization Name:MARTIN JACOBSON, D.C., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-725-7003
Mailing Address - Street 1:1051 PORT MALABAR BLVD. NE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905
Mailing Address - Country:US
Mailing Address - Phone:321-725-7003
Mailing Address - Fax:
Practice Address - Street 1:1051 PORT MALABAR BLVD NE
Practice Address - Street 2:SUITE 2
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5153
Practice Address - Country:US
Practice Address - Phone:321-725-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004008111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051196000Medicaid
88860Medicare PIN