Basic Information
| Provider Information | |||||||||
| NPI: | 1003909193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122635072 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | L2345 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | L2345 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 124217 | 01 | TX | SUPERIOR PIN | OTHER | 1447220850 | 01 | GRP NPI NUMBER | OTHER | 1950571 | 01 | TX | UHC PIN | OTHER | 10030778 | 01 | TX | AMERIGROUP PIN | OTHER | 7067290 | 01 | TX | AETNA PIN | OTHER | 0324290 | 01 | TX | CIGNA PIN | OTHER | 147834901 | 05 | TX | MEDICAID | 1192925 | 01 | TX | FIRSTHEALTH PIN | OTHER | 140442853 | 05 | TX | MEDICAID | 00N47F | 01 | TX | BCBSTX GRP PIN | OTHER | 147834902 | 05 | TX | MEDICAID | 115891100 | 01 | TX | FIRSTCARE PIN | OTHER | 137345809 | 05 | TX | MEDICAID | 88413Y | 01 | TX | BCBSTX IND PIN | OTHER | 9187586 | 01 | TX | PHCS PIN | OTHER |