Basic Information
| Provider Information | |||||||||
| NPI: | 1346357860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | GARY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146476326 | ||||||||
| FaxNumber: | 4146718860 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 KENOSHA ST | ||||||||
| Address2: | #A | ||||||||
| City: | WALWORTH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622752101 | ||||||||
| FaxNumber: | 2622750752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23975 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30394600 | 05 | WI | MEDICAID | AJ8980876 | 01 | DEA NUMBER | OTHER |