Provider Demographics
NPI:1629125018
Name:JACOBSEN, TIMOTHY DEAN
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:DEAN
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 TAYLOR AVENUE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-4641
Mailing Address - Country:US
Mailing Address - Phone:402-371-7545
Mailing Address - Fax:402-379-0583
Practice Address - Street 1:2108 TAYLOR AVENUE
Practice Address - Street 2:SUITE 1100
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4641
Practice Address - Country:US
Practice Address - Phone:402-371-7545
Practice Address - Fax:402-379-0583
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1330225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025464600Medicaid