Healthcare Provider Details

I. General information

NPI: 1205284098
Provider Name (Legal Business Name): ERIC STEFAN JACOBSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 ACE DR
BEREA KY
40403-1327
US

IV. Provider business mailing address

1006 ACE DR
BEREA KY
40403-1327
US

V. Phone/Fax

Practice location:
  • Phone: 859-286-6999
  • Fax: 859-406-1333
Mailing address:
  • Phone: 859-286-6999
  • Fax: 859-406-1333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9750
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number9750
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: