Provider Demographics
NPI:1457324253
Name:JACOBSON, DYAN MARIE (PHYSICALTHERAPISTMPT)
Entity Type:Individual
Prefix:MRS
First Name:DYAN
Middle Name:MARIE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHYSICALTHERAPISTMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-0360
Mailing Address - Country:US
Mailing Address - Phone:507-288-4416
Mailing Address - Fax:
Practice Address - Street 1:1620 17TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2839
Practice Address - Country:US
Practice Address - Phone:507-332-2204
Practice Address - Fax:507-332-2270
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6401148OtherMEDICA IND PROVIDER #
MN2032898OtherARAZ IND PROVIDER #
MN33G05JAOtherBCBS INDIVIDUAL PROVIDER#
MNHP42458OtherHEALTH PARTNERS IND PRO#
MN11613OtherU-CARE PROVIDER #