Provider Demographics
NPI:1215123336
Name:WILLIAM M. JACOBSEN MD PC
Entity type:Organization
Organization Name:WILLIAM M. JACOBSEN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-212-0100
Mailing Address - Street 1:2400 E AZ BILTMORE CIR
Mailing Address - Street 2:STE 2450
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2107
Mailing Address - Country:US
Mailing Address - Phone:602-212-0100
Mailing Address - Fax:602-279-1701
Practice Address - Street 1:2400 E AZ BILTMORE CIR
Practice Address - Street 2:STE 2450
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2107
Practice Address - Country:US
Practice Address - Phone:602-212-0100
Practice Address - Fax:602-279-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21620208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty