Provider Demographics
NPI:1962456772
Name:JACOBSON, ELLEN R (MD)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:R
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:615-322-6842
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-8573
Practice Address - Country:US
Practice Address - Phone:615-322-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000019503174400000X
TN19503207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6049042OtherBCBS
TNE98089Medicare UPIN
TN6049042OtherBCBS