Basic Information
| Provider Information | |||||||||
| NPI: | 1750391280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747300 | ||||||||
| FaxNumber: | 5166741779 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SAINT ANDREWS LN | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115422254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166747591 | ||||||||
| FaxNumber: | 5166741779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 002421 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.