Provider Demographics
NPI:1962568873
Name:JACOBSEN, THOMAS ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ROBERT
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5585 MELLOWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-6105
Mailing Address - Country:US
Mailing Address - Phone:530-877-9351
Mailing Address - Fax:
Practice Address - Street 1:5974 PENTZ RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5509
Practice Address - Country:US
Practice Address - Phone:530-877-9361
Practice Address - Fax:530-876-7935
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0008943183500000X
CARPH 46785183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist