Trevor Dean Jacobson, M.D.
Individual provider Active NPI Family Medicine Physician · Montpelier, ID
NPI 1366677759 · NPPES record last updated Dec 11, 2014
Key facts
- NPI
- 1366677759
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- M-12665 (ID)
- Practice address
- 166 S 5TH St
Montpelier, ID 83254-4959 - Phone
- (208) 847-1110
- Fax
- (208) 847-0228
- NPI assigned
- May 28, 2009
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 8
Hospital & facility affiliations 4
Owned or controlled facilities with NPI records 1
Medicare Care Compare profile
- Specialty
- Family Practice
- Education
- University of Utah School of Medicine, 2009
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Bear Lake County Memorial Hospital
Practice addresses (Care Compare)
164 S
Montpelier, ID 83254-1557
164 S 5TH St
Montpelier, ID 83254-1557
166 S 5TH St
Montpelier, ID 83254-1557
Phone (208) 847-1110
465 Washington St
Montpelier, ID 83254-1544
Phone (208) 847-4495
467 Washington St
Montpelier, ID 83254-1544
Phone (208) 847-4495
Hospital & facility affiliations
- Bear Lake Memorial Hospital Home Health
- Bear Lake Memorial Hospital
- Intermountain Health Logan Regional Hospital
- Bear Lake Memorial Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Bear Lake Memorial Skilled Nursing Facility |
Skilled nursing facility | Corporate Director (10%) Operational/Managerial Control Adp of the SNF |
Oct 20, 2016 Oct 20, 2016 Jun 14, 2022 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20141226000672 | ID | Practitioner - Family Practice | 1052560661 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| M-12665 | ID | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Bear Lake County Memorial Hospital | Current |
Accepting new patients | |
| Bear Lake County Memorial Hospital | Family Medicine | Current |
Accepting new patients |
Locations
166 S 5th St
Montpelier, ID 83254
Phone (208) 847-1110
Interoperability endpoints
- tjacobson620120@direct.ochin.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | M-12665 | ID | Yes |
Addresses
Primary practice location
166 S 5TH St
Montpelier, ID 83254-4959
Mailing address
PO Box 69
Montpelier, ID 83254-0069
Phone (208) 847-1110
Other providers in Montpelier, ID
- Brandon J. Henscheid
- Casey Humpherys
- Ory Brad Hutchison
- Gregory William Hyde
- Flint Dean Jacobson
- Marilee Johnson
- Joseph F Decker Professional Corp
- Josh Bowman DC PLLC
- Angela K Kelly
- Bobbi Jae Kelsey
All providers in Montpelier, ID · Family Medicine Physician in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 11, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.