Basic Information
Provider Information | |||||||||
NPI: | 1588684260 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBSON | ||||||||
FirstName: | JASON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19 BRADHURST AVE STE 3100N | ||||||||
Address2: |   | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149099018 | ||||||||
FaxNumber: | 9149099028 | ||||||||
Practice Location | |||||||||
Address1: | 19 BRADHURST AVE | ||||||||
Address2: | SUITE 3850S | ||||||||
City: | HAWTHORNE | ||||||||
State: | NY | ||||||||
PostalCode: | 105322140 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9149096900 | ||||||||
FaxNumber: | 9144932828 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 215349 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 036-115096 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 036-115096 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 215349 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
ID | Type | State | Issuer | Description | ME110088 | 01 | FL | MEDICAL LICENSE | OTHER | 003947600 | 05 | FL |   | MEDICAID | 03917264 | 05 | NY |   | MEDICAID |