Provider Demographics
NPI:1578531836
Name:JACOBSON, BETH JEAN (PT, ATC)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:JEAN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
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Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:BLDG 3, SUITE 461
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-589-0850
Mailing Address - Fax:619-589-0878
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:BLDG 3, SUITE 461
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-589-0850
Practice Address - Fax:619-589-0878
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPT89862251S0007X, 2251X0800X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT8986Medicare ID - Type UnspecifiedLICENSE NUMBER