Healthcare Provider Details

I. General information

NPI: 1689940405
Provider Name (Legal Business Name): LANCE GLEN JACOBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A205
IDAHO FALLS ID
83404-7586
US

IV. Provider business mailing address

PO BOX 277381
ATLANTA GA
30384-7381
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberM-14018
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-14018
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: