Healthcare Provider Details

I. General information

NPI: 1043514391
Provider Name (Legal Business Name): DONALD M. JACOBSON, MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 DURAND AVE STE 325
RACINE WI
53405-4480
US

IV. Provider business mailing address

3701 DURAND AVE STE 325
RACINE WI
53405-4480
US

V. Phone/Fax

Practice location:
  • Phone: 262-598-9030
  • Fax: 262-598-9032
Mailing address:
  • Phone: 262-598-9030
  • Fax: 262-598-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number33729
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number33729
License Number StateWI

VIII. Authorized Official

Name: MRS. JOAN JACOBSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 262-930-6522