Healthcare Provider Details

I. General information

NPI: 1104862929
Provider Name (Legal Business Name): MARTIN A JACOBSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 KEPLER DR
GREEN BAY WI
54311-8321
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5656
  • Fax: 920-288-5657
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2782
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: