Provider Demographics
NPI:1194731232
Name:JACOBSEN, STEVEN VERGIL (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:VERGIL
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68026-0072
Mailing Address - Country:US
Mailing Address - Phone:402-727-9220
Mailing Address - Fax:402-727-5625
Practice Address - Street 1:1445 N BELL ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-3534
Practice Address - Country:US
Practice Address - Phone:402-727-9220
Practice Address - Fax:402-727-5625
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE780152W00000X
IA01542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE410016544OtherPALMETTO GBA RAILROAD MED
NE410016544OtherPALMETTO GBA RAILROAD MED
NE096435Medicare PIN