=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245294214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WELLS C JACOBSON MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2006
-----------------------------------------------------
Last Update Date | 02/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 HAYNES ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-0188
-----------------------------------------------------
Fax | 860-645-9573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 HAYNES ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06040-4105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-646-0188
-----------------------------------------------------
Fax | 860-645-9573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 022276
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------