Provider Demographics
NPI:1366558470
Name:WALTER E. JACOBSON, MD, INC.
Entity type:Organization
Organization Name:WALTER E. JACOBSON, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-885-8599
Mailing Address - Street 1:5699 KANAN RD
Mailing Address - Street 2:#433
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-3358
Mailing Address - Country:US
Mailing Address - Phone:818-885-8500
Mailing Address - Fax:818-865-2124
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:IFL TOWER, 4TH FLOOR
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4105
Practice Address - Country:US
Practice Address - Phone:818-885-8500
Practice Address - Fax:818-865-2124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA610162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA61016Medicare ID - Type Unspecified
CAG38699Medicare UPIN