Individual
CHARLES D JACOBSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1701 3RD ST SE, PUYALLUP, WA 98372-4511
(253) 967-5767
(253) 697-5682
Mailing address
1701 3RD ST SE, PUYALLUP, WA 98372-4511
(253) 967-5767
(253) 697-5682
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD00013535
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
111661110
MEDICARE OTHER-INDIVIDUAL
WA
05
—
1414200
—
WA
01
—
193400000X
TAXONOMY
WA
01
—
CO3401
MEDICARE OTHER-GROUP
WA
Enumeration date
02/13/2006
Last updated
11/08/2011
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