Provider Demographics
NPI:1477768653
Name:JACOBSEN, BRUCE A (PT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WHITE BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2159
Mailing Address - Country:US
Mailing Address - Phone:203-458-3466
Mailing Address - Fax:
Practice Address - Street 1:84 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3009
Practice Address - Country:US
Practice Address - Phone:203-789-3490
Practice Address - Fax:203-488-7129
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist