Provider Demographics
NPI:1053032656
Name:JACOBSON, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16740 E 11 MILE RD APT 101
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5119
Mailing Address - Country:US
Mailing Address - Phone:586-943-0680
Mailing Address - Fax:
Practice Address - Street 1:400 STODDARD RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-2505
Practice Address - Country:US
Practice Address - Phone:810-392-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist