Provider Demographics
NPI:1073608683
Name:JACOBS, KIMBERLY ILEANA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ILEANA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 PRAIRIE CT
Mailing Address - Street 2:
Mailing Address - City:EASTR TROY
Mailing Address - State:WI
Mailing Address - Zip Code:53120
Mailing Address - Country:US
Mailing Address - Phone:262-642-9067
Mailing Address - Fax:262-363-3014
Practice Address - Street 1:727 HWY NN
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149
Practice Address - Country:US
Practice Address - Phone:262-363-3014
Practice Address - Fax:262-363-3019
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3746-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40753300Medicaid
WI40753300Medicaid