Provider Demographics
NPI:1417206418
Name:JACOBSON, MARY ELISABETH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELISABETH
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1125
Mailing Address - Country:US
Mailing Address - Phone:217-784-2088
Mailing Address - Fax:
Practice Address - Street 1:725 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-1125
Practice Address - Country:US
Practice Address - Phone:217-784-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist