Healthcare Provider Details

I. General information

NPI: 1639189640
Provider Name (Legal Business Name): JACQUELINE JACOBSON DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 UNION ST
MARLBOROUGH MA
01752
US

IV. Provider business mailing address

PO BOX 419 126 UNION ST
MARLBOROUGH MA
01752-0419
US

V. Phone/Fax

Practice location:
  • Phone: 508-787-0070
  • Fax: 508-787-0071
Mailing address:
  • Phone: 508-787-0070
  • Fax: 508-787-0071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number18875
License Number StateMA

VIII. Authorized Official

Name: DR. JACQUELINE Y JACOBSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 508-787-0070