Healthcare Provider Details

I. General information

NPI: 1003877176
Provider Name (Legal Business Name): JACOB L FRIESEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE WRNMMC, NICOE, BUILDING 51
BETHESDA MD
20889
US

IV. Provider business mailing address

12732 MIDDLEVALE LN
SILVER SPRING MD
20906-3339
US

V. Phone/Fax

Practice location:
  • Phone: 301-319-3772
  • Fax:
Mailing address:
  • Phone: 301-873-8145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0054171
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberD0054171
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: