MEDICARE: WENDY JACOBSON MD PC M.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
1	2084P0800X	Psychiatry Physician	038811	GA

General Provider Information

NPI Number	:	1619006921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY JACOBSON MD PC M.D.

Provider Business Mailing Address
First Line	:	1485 LAVISTA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3846
Country	:	US
Telephone Number	:	404-325-5677
Fax Number	:	404-325-9029

Provider Business Practice Location Address
First Line	:	1485 LAVISTA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30324-3846
Country	:	US
Telephone Number	:	404-325-5677
Fax Number	:	404-325-9029

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

Provider Enumeration Date	:	03/04/2007
Last Update Date	:	07/13/2012

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