Basic Information
| Provider Information | |||||||||
| NPI: | 1366558470 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WALTER E. JACOBSON, MD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5699 KANAN RD | ||||||||
| Address2: | #433 | ||||||||
| City: | AGOURA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913013358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | 8188652124 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 ROSCOE BLVD | ||||||||
| Address2: | IFL TOWER, 4TH FLOOR | ||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | 8188652124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSON | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
| AuthorizedOfficialMiddleName: | ERIC | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8188858599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A61016 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.