MEDICARE: DR. JEFFREY LEE JACOBSON OD

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	152W00000X	Optometrist	ODTA00319	RI

General Provider Information

NPI Number	:	1689626947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY LEE JACOBSON OD

Provider Business Mailing Address
First Line	:	2921 ERIE BLVD EAST
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13224
Country	:	US
Telephone Number	:	315-445-7665
Fax Number	:	315-445-7675

Provider Business Practice Location Address
First Line	:	1400 OAKLAWN AVE
Second Line	:	OPTOMETRIC PROVIDERS OF RHODE ISLAND, INC
City	:	CRANSTON
State	:	RI
Zip	:	02920-2643
Country	:	US
Telephone Number	:	401-463-6696
Fax Number	:	401-463-5913

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	09/04/2007

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