Provider Demographics
NPI:1255518635
Name:JACOBSON OPTOMETRY LTD
Entity type:Organization
Organization Name:JACOBSON OPTOMETRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:715-234-3113
Mailing Address - Street 1:1801 W KNAPP ST STE 3
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1381
Mailing Address - Country:US
Mailing Address - Phone:715-234-3113
Mailing Address - Fax:715-234-2339
Practice Address - Street 1:1801 W KNAPP ST STE 3
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1381
Practice Address - Country:US
Practice Address - Phone:715-234-3113
Practice Address - Fax:715-234-2339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38527700Medicaid
WI38527700Medicaid