Provider Demographics
NPI:1629275995
Name:JACOBSEN, MARCI MEDENWALD (BS, BS, AAS)
Entity Type:Individual
Prefix:MRS
First Name:MARCI
Middle Name:MEDENWALD
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:BS, BS, AAS
Other - Prefix:
Other - First Name:MARCI
Other - Middle Name:KAYE
Other - Last Name:MEDENWALD SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:4301 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:972-400-0287
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1207224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant