Provider Demographics
NPI:1427504745
Name:JACOBSON, MIRIAM (RD)
Entity type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 GRIFFITH PARK BLVD
Mailing Address - Street 2:APT 1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-3500
Mailing Address - Country:US
Mailing Address - Phone:917-545-8860
Mailing Address - Fax:
Practice Address - Street 1:2100 GRIFFITH PARK BLVD
Practice Address - Street 2:APT 1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-3500
Practice Address - Country:US
Practice Address - Phone:917-545-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007730-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered