Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1447432125 |
---|---|
Provider Name | Mr. Carl J Jacobsen SR. |
First Address | Jenkintown, PA 19046-2710 |
Second Address | Jenkintown, PA 19046-2710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2007 |
Last Update Date | 04/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0743370001 | PROVIDER NUMBER (01) |