Provider Demographics
NPI:1588762595
Name:JACOBSON, LISA (OD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-4312
Mailing Address - Country:US
Mailing Address - Phone:781-444-5435
Mailing Address - Fax:
Practice Address - Street 1:400 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-1263
Practice Address - Country:US
Practice Address - Phone:781-444-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3837152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0392448Medicaid
MA054585Medicare UPIN
MAW16000Medicare ID - Type Unspecified