MEDICARE: DR. DANIEL RAYMOND JACOBSON 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	208D00000X	General Practice Physician	036075975	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	036075975	OTHER	IL	PHYSICIAN LICENSE

General Provider Information

NPI Number	:	1447231063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL RAYMOND JACOBSON M.D.

Provider Business Mailing Address
First Line	:	1413 W LEXINGTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4013
Country	:	US
Telephone Number	:	312-421-1133
Fax Number	:	312-421-1133

Provider Business Practice Location Address
First Line	:	1413 W LEXINGTON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4013
Country	:	US
Telephone Number	:	312-421-1226
Fax Number	:	312-421-1133

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

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	11/16/2020

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