MEDICARE: W JACOBSEN DPM PROFESSIONAL CORPORATION

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	213ES0103X	Foot & Ankle Surgery Podiatrist	016004485	IL

General Provider Information

NPI Number	:	1801060561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W JACOBSEN DPM PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1126 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4410
Country	:	US
Telephone Number	:	773-561-7626
Fax Number	:	773-561-1111

Provider Business Practice Location Address
First Line	:	1126 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4410
Country	:	US
Telephone Number	:	773-561-7626
Fax Number	:	773-561-1111

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WALTER JOSEPH JACOBSEN
Credential	:	DPM
Telephone Number	:	773-561-7626

Provider Enumeration Date	:	04/14/2008
Last Update Date	:	11/09/2010

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