=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457541377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIKAEL JACOBSON, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2007
-----------------------------------------------------
Last Update Date | 07/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4242 MEDICAL DR STE 1150
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-5640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-593-1530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2827 BRIARFIELD DR
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78230-4411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-593-1530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MIKAEL JACOBSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 210-593-1530
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | L5386
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------