Provider Demographics
NPI:1134510647
Name:JACOBSON, GRANT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5627 NW 86TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1738
Mailing Address - Country:US
Mailing Address - Phone:515-270-0303
Mailing Address - Fax:515-270-0160
Practice Address - Street 1:1810 SW WHITE BIRCH CIR STE 107
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7226
Practice Address - Country:US
Practice Address - Phone:515-964-8885
Practice Address - Fax:515-964-4557
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist