Healthcare Provider Details

I. General information

NPI: 1316393648
Provider Name (Legal Business Name): TAM JACOBSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11631 MIRO CIR
SAN DIEGO CA
92131-3320
US

IV. Provider business mailing address

11631 MIRO CIR
SAN DIEGO CA
92131-3320
US

V. Phone/Fax

Practice location:
  • Phone: 858-761-4003
  • Fax:
Mailing address:
  • Phone: 858-761-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number53271
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number53271
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number53271
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: