Healthcare Provider Details

I. General information

NPI: 1811057623
Provider Name (Legal Business Name): BRETT DEAN JACOBSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 PANCHERI DR
IDAHO FALLS ID
83402-3344
US

IV. Provider business mailing address

885 PANCHERI DR
IDAHO FALLS ID
83402-3344
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-0870
  • Fax: 208-524-0873
Mailing address:
  • Phone: 208-524-0870
  • Fax: 208-524-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberD-3203
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: