Healthcare Provider Details

I. General information

NPI: 1205412038
Provider Name (Legal Business Name): TYLER WILLIAM JACOBSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date: 06/27/2022
Reactivation Date: 07/22/2022

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-7271
  • Fax:
Mailing address:
  • Phone: 401-444-5172
  • Fax: 401-444-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD20676
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMED-PHYS-LIC-156063
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: