Provider Demographics
NPI:1972509917
Name:JACOBSON, NEIL (PT)
Entity type:Individual
Prefix:MR
First Name:NEIL
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-5519
Mailing Address - Country:US
Mailing Address - Phone:805-338-1769
Mailing Address - Fax:
Practice Address - Street 1:5725 RALSTON ST
Practice Address - Street 2:STE 103
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6053
Practice Address - Country:US
Practice Address - Phone:805-658-6964
Practice Address - Fax:805-644-4576
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT010704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT010704Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAPT010704Medicare UPIN