Healthcare Provider Details

I. General information

NPI: 1942405246
Provider Name (Legal Business Name): LAWRENCE M. JACOBY, M.D., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W AVON RD
AVON CT
06001-3583
US

IV. Provider business mailing address

18 W AVON RD
AVON CT
06001-3583
US

V. Phone/Fax

Practice location:
  • Phone: 860-673-1667
  • Fax: 860-673-1544
Mailing address:
  • Phone: 860-673-1667
  • Fax: 860-673-1544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000178
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number016756
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number022522
License Number StateCT

VIII. Authorized Official

Name: MS. JODIE JACOBY
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-673-1667