Basic Information
| Provider Information | |||||||||
| NPI: | 1548749583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | TEGAN | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OTT | ||||||||
| OtherFirstName: | TEGAN | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5500 ARMSTRONG RD | ||||||||
| Address2: | 119A | ||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699665600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5500 ARMSTRONG RD | ||||||||
| Address2: | 119A | ||||||||
| City: | BATTLE CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699665600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 63111 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.