Provider Demographics
NPI:1588761662
Name:JACOBSEN, ADAM E (PA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:E
Last Name:JACOBSEN
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Gender:M
Credentials:PA
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Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:STE 640
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-6255
Practice Address - Fax:315-464-6251
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-05-05
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Provider Licenses
StateLicense IDTaxonomies
NY008124363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848153Medicaid