Basic Information
| Provider Information | |||||||||
| NPI: | 1356364384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | MIKAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8111 MAINLAND DR | ||||||||
| Address2: | SUITE 104448 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782403748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103635471 | ||||||||
| FaxNumber: | 8884713818 | ||||||||
| Practice Location | |||||||||
| Address1: | 8550 HUEBNER RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782401803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105415300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | L5386 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 551369 | 01 | TX | VALUE OPTIONS # | OTHER | 8DJ721 | 01 | TX | BCBSTX | OTHER | 175829401 | 01 | TX | TMHP | OTHER | 202949040 | 01 | TX | TRICARE PROVIDER ID | OTHER | L5386 | 01 | TX | TEXAS STATE LICENSE # | OTHER | 8S7470 | 01 | TX | BCBS PROVIDER # | OTHER | 164124306 | 05 | TX | MEDICAID | BJ8081426 | 01 | TX | DEA NUMBER | OTHER |