Healthcare Provider Details

I. General information

NPI: 1043298193
Provider Name (Legal Business Name): SANDRA A JACOBSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2006
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10515 W SANTA FE DR
SUN CITY AZ
85351-3020
US

IV. Provider business mailing address

PO BOX 53568
PHOENIX AZ
85072-3568
US

V. Phone/Fax

Practice location:
  • Phone: 623-875-6500
  • Fax:
Mailing address:
  • Phone: 623-544-5075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD11353
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: