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NPI Code Detail

MEDICARE: DR. MARK WILLIAM JACOBSON PH.D.

MEDICARE: DR. MARK WILLIAM JACOBSON PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103G00000XClinical NeuropsychologistPSY16985CA
2103TC0700XClinical PsychologistPSY16985CA

General Provider Information

NPI Number : 1194837807
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARK WILLIAM JACOBSON PH.D.
Provider Business Mailing Address
First Line : 4103 1ST AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92103-2024
Country : US
Telephone Number : 619-296-8546
Fax Number :
Provider Business Practice Location Address
First Line : 4103 1ST AVE
Second Line :
City : SAN DIEGO
State : CA
Zip : 92103-2024
Country : US
Telephone Number : 619-296-8546
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2006
Last Update Date : 09/11/2025

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