Provider Demographics
NPI:1619027836
Name:JACOBSEN, JONATHAN VIRGIL (MPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VIRGIL
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 N 1300 E
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-9009
Mailing Address - Country:US
Mailing Address - Phone:801-766-3729
Mailing Address - Fax:
Practice Address - Street 1:680 E MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2251
Practice Address - Country:US
Practice Address - Phone:801-768-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53121142401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist