MEDICARE: DR. JORDAN IRA JACOBSON D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	051487	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051487	OTHER	NY	DENTAL LICENSE

General Provider Information

NPI Number	:	1194818898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORDAN IRA JACOBSON D.M.D

Provider Business Mailing Address
First Line	:	231 E 106TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-4005
Country	:	US
Telephone Number	:	212-348-0020
Fax Number	:	646-219-2039

Provider Business Practice Location Address
First Line	:	231 E 106TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-4005
Country	:	US
Telephone Number	:	212-348-0020
Fax Number	:	646-219-2039

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	06/17/2009

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