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Status: Active (Since 07/21/2005)

DR. LEE R JACOBSON OD

NPI Number
1386644284
Entity Type
Individual
Healthcare Provider/Organization Name
DR. LEE R JACOBSON OD
Black Classic up Hi Adults Unisex Pewter SK8 Top Hi Sneaker Lace Vans Checkerboard Provider Business Mailing Address
First Line
1357 2ND AVE
Second Line
 
City
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CUMBERLAND
State
WI
Postal Code (Zip)
54829-7211
Country
US
Phone
715-822-2091
Fax
715-822-3624
Provider Business Practice Location
First Line
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1357 2ND AVE
Second Line
 
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CUMBERLAND
State
WI
Postal Code (Zip)
54829-7211
Country
US
Phone
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Fax
715-822-3624
Authorized Official
Title or Position
 
Name
 
Credential
   
Telephone Number
 
Provider Enumeration Date
07/21/2005
Last Updated
12/14/2009
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Detailed Information

NPI Number 1386644284 has the "Individual" type of ownership and has been registered to the following primary business legal name (which is a provider name or healthcare organization name) — DR. LEE R JACOBSON OD. Records indicate that the provider gender is "Male". The enumeration date of this NPI Number is 07/21/2005. NPI Number information was last updated on 12/14/2009.

The provider is physically located (Business Practice Location) at:

1357 2ND AVE
CUMBERLAND, WI
54829-7211, US

DR. LEE R JACOBSON OD can be reached at his practice location using the following numbers:

Phone:
715-822-2091
Fax:
715-822-3624

The provider's official mailing address is:

1357 2ND AVE
CUMBERLAND, WI
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54829-7211, US

The contact numbers associated with the mailing address are:

Phone:
715-822-2091
Fax:
715-822-3624

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy Specialty License Number Vans SK8 Classic up Adults Checkerboard Hi Unisex Sneaker Top Black Pewter Hi Lace LicenseState
1 152W00000X Optometrist 1298 WI

Legacy (Non-NPI) Identifiers

For crosswalk purposes, the following (non-NPI) identifiers are available for this provider:

# Provider Identifier Identifier Type Identifier State Issuer
1 410011362 OTHER WI SK8 Lace Black Unisex Sneaker Pewter Hi Classic up Top Adults Checkerboard Hi Vans RR-PTAN 410011362
2 410040506 OTHER WI RR-PTAN 410040506
3 38541900 Adults Hi Top Vans Black Hi Classic SK8 Lace Sneaker Unisex Checkerboard up Pewter MEDICAID WI

Legacy & Proprietary Identifiers Ever Reported To NPPES

Collection of legacy and proprietary (non NPI) identifiers ever reported for this provider:

# Provider Identifier Identifier Type Identifier State Issuer
1 000147425 MEDICARE PIN WI
2 000147430 MEDICARE PIN WI
3 0321190001 MEDICARE NSC WI
4 0321190002 MEDICARE NSC WI
5 38541900 MEDICAID WI
6 410011362 OTHER WI RR-PTAN 410011362
7 410040506 OTHER WI RR-PTAN 410040506
8 T62295 MEDICARE UPIN

Reference NPI Information. Full replica of the CMS (NPPES) NPI record

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Field Name Value
NPI 1386644284
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Unisex Top Vans up Checkerboard Hi Classic Lace Pewter Black Adults Sneaker Hi SK8 Entity Type Individual
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Is Sole Proprietor N
Indicate whether provider is a sole proprietor.
  • A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.
  • In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.
  • There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.
  • In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).
  • As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)
  • A sole proprietorship may or may not have employees.
  • Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's EIN.
  • Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).
Provider Last Name (Legal Name) JACOBSON
The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Name LEE
The first name of the provider, if the provider is an individual.
Provider Middle Name R
The middle name of the provider, if the provider is an individual.
Provider Name Prefix Text DR.
The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
Provider Credential Text OD
Black Lace Unisex Adults Hi Hi up Sneaker Pewter SK8 Vans Classic Top Checkerboard The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider First Line Business Mailing Address 1357 2ND AVE
The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.
Provider Business Mailing Address City Name CUMBERLAND
The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.
Provider Business Mailing Address State Name WI
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.
Provider Business Mailing Address Postal Code 54829-7211
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.
Provider Business Mailing Address Country Code US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.
Provider Business Mailing Address Telephone Number 715-822-2091
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.
Provider Business Mailing Address Fax Number 715-822-3624
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.
Provider First Line Business Practice Location Address 1357 2ND AVE
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name CUMBERLAND
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name WI
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code 54829-7211
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code up Hi Vans Hi Adults Top Black Lace SK8 Unisex Sneaker Pewter Classic Checkerboard US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number 715-822-2091
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number Black Classic Unisex Lace Checkerboard SK8 Adults Sneaker Vans Hi Top Pewter Hi up 715-822-3624
SK8 Hi Unisex Lace Top Adults Checkerboard Hi Black Vans up Classic Sneaker Pewter The fax number associated with the location address of the provider being identified.
Provider Enumeration Date 07/21/2005
Unisex Pewter Adults Black Checkerboard Top SK8 up Vans Classic Sneaker Hi Hi Lace The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date 12/14/2009
The date that a record was last updated or changed.
Provider Gender Code M
The code designating the provider's gender if the provider is a person.
Provider Gender Male
The provider's gender if the provider is a person.
Healthcare Provider Taxonomy Code #1 152W00000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1 Optometrist
Healthcare Provider Taxonomy #1
Provider License Number 1 1298
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 1 WI
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Healthcare Provider Primary Taxonomy Switch 1 Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Other Provider Identifier 1 410011362
Other Provider Identifier #1
Other Provider Identifier Type 1 OTHER
Other Provider Identifier Type #1
Other Provider Identifier State 1 WI
Other Provider Identifier State #1
Other Provider Identifier Issuer 1 RR-PTAN 410011362
Other Provider Identifier Issuer #1
Other Provider Identifier 2 410040506
Other Provider Identifier #2
Other Provider Identifier Type 2 OTHER
Other Provider Identifier Type #2
Other Provider Identifier State 2 WI
Other Provider Identifier State #2
Other Provider Identifier Issuer 2 RR-PTAN 410040506
Other Provider Identifier Issuer #2
Other Provider Identifier 3 38541900
Other Provider Identifier #3
Other Provider Identifier Type 3 MEDICAID
Other Provider Identifier Type #3
Other Provider Identifier State 3 WI
Other Provider Identifier State #3

Driving Directions to "DR. LEE R JACOBSON OD" Practice Location

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