Provider Demographics
NPI:1053405969
Name:JACOBSEN, ERIC S (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:S
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W. FORT ST.
Mailing Address - Street 2:# 111
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-422-1000
Mailing Address - Fax:208-422-1319
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003760600Medicaid
ID000010139751OtherBLUE SHIELD
ID50450OtherBLUE CROSS
ID003760600Medicaid
ID000010139751OtherBLUE SHIELD
F52096Medicare UPIN