Provider Demographics
NPI:1639738461
Name:JACOBSON, CYNTHIA L (OTR/L , MED)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:L
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:OTR/L , MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 N PEORIA ST APT 4H
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2648
Mailing Address - Country:US
Mailing Address - Phone:312-733-0511
Mailing Address - Fax:
Practice Address - Street 1:1000 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1970
Practice Address - Country:US
Practice Address - Phone:708-234-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.000829225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist