Provider Demographics
NPI:1558813394
Name:JACOBY, ALEXANDER (ATC)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:JACOBY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N WARPOLE ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615
Mailing Address - Country:US
Mailing Address - Phone:419-310-4541
Mailing Address - Fax:
Practice Address - Street 1:1001 N WARPOLE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:419-310-4541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0049982255A2300X
MI26010017282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer