Provider Demographics
NPI:1063033827
Name:JACOBSEN, DEANN MARIE (MS, PTA, ATC)
Entity Type:Individual
Prefix:
First Name:DEANN
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MS, PTA, ATC
Other - Prefix:
Other - First Name:DEANN
Other - Middle Name:MARIE
Other - Last Name:PIAZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8750 BRIARCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-2519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8750 BRIARCLIFF LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-2519
Practice Address - Country:US
Practice Address - Phone:916-718-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
CAPTA5287225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer