Provider Demographics
NPI:1598210841
Name:JACOBSON, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 NE GREENWOOD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4569
Mailing Address - Country:US
Mailing Address - Phone:541-390-2548
Mailing Address - Fax:
Practice Address - Street 1:2437 NW LOLO DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7318
Practice Address - Country:US
Practice Address - Phone:541-390-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21986225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist