MEDICARE: DR. LOIS JEAN JACOBS M.D.,PHD

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
1	207R00000X	Internal Medicine Physician	30302	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	202960478012	OTHER	WI	BCBSWI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306843321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LOIS JEAN JACOBS M.D.,PHD

Provider Business Mailing Address
First Line	:	1510 ARBORETUM DR
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54901-2790
Country	:	US
Telephone Number	:	920-231-5313
Fax Number	:	920-231-5348

Provider Business Practice Location Address
First Line	:	1510 ARBORETUM DR
Second Line	:
City	:	OSHKOSH
State	:	WI
Zip	:	54901-2790
Country	:	US
Telephone Number	:	920-231-5313
Fax Number	:	920-231-5348

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	06/30/2008

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