Provider Demographics
NPI:1568434892
Name:JACOBSEN, KURT BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:BRADLEY
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6507 TOWN CENTER DR STE F
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4826
Mailing Address - Country:US
Mailing Address - Phone:248-625-7600
Mailing Address - Fax:248-625-2772
Practice Address - Street 1:6507 TOWN CENTER DR STE F
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4826
Practice Address - Country:US
Practice Address - Phone:248-625-7600
Practice Address - Fax:248-625-2772
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKJ002655111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOF35070Medicare ID - Type Unspecified
T33355Medicare UPIN