Provider Demographics
NPI:1558654319
Name:JACOBSEN, LARA (PT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 YORKTOWN LN
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2221
Mailing Address - Country:US
Mailing Address - Phone:973-720-1215
Mailing Address - Fax:
Practice Address - Street 1:550 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1500
Practice Address - Country:US
Practice Address - Phone:201-262-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01172900225100000X
FLPT23450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist