Individual
CHARLES A JACOBSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2500 W A ST, SUITE 201, MOSCOW, ID 83843-5065
(208) 883-2828
(208) 882-2179
Mailing address
2500 W A ST, SUITE 201, MOSCOW, ID 83843-5065
(208) 883-2828
(208) 882-2179
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
31851
WA
207X00000X
Orthopaedic Surgery Physician
Primary
M6567
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002743901
—
ID
01
—
0102784
DEPT OF LABOR
WA
05
—
1092733
—
WA
Enumeration date
08/09/2006
Last updated
08/04/2015
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