Provider Demographics
NPI:1013189414
Name:JACOBSON, LINDSEY (PTA)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2176
Mailing Address - Street 2:DEPT 5389
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-2176
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:3475 S ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2604
Practice Address - Country:US
Practice Address - Phone:815-874-8000
Practice Address - Fax:815-874-7525
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004616225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL769380Medicare PIN