Provider Demographics
NPI:1699797662
Name:JON JACOBSON, II, DDS, PC
Entity type:Organization
Organization Name:JON JACOBSON, II, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-754-7500
Mailing Address - Street 1:1016 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4325
Mailing Address - Country:US
Mailing Address - Phone:989-754-7500
Mailing Address - Fax:989-754-7780
Practice Address - Street 1:1016 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4325
Practice Address - Country:US
Practice Address - Phone:989-754-7500
Practice Address - Fax:989-754-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010094231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID094230OtherBLUE CROSS BLUE SHIELD
MI1849313Medicaid