Individual
DR. GARY D JACOBSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
3111 W CHANDLER BLVD, SUITE 2104, CHANDLER, AZ 85226-5071
(480) 726-7009
Mailing address
3468 E HAZELTINE WAY, CHANDLER, AZ 85249-9167
(406) 939-1309
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
453
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
011003936
MEDICARE PTAN
—
05
—
0480350
—
MT
Enumeration date
11/02/2005
Last updated
02/08/2014
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