Provider Demographics
NPI:1679288344
Name:JACOBSON, TATE RYLEY
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:RYLEY
Last Name:JACOBSON
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 1:201 E RUDISILL BLVD STE 100B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1756
Mailing Address - Country:US
Mailing Address - Phone:260-615-1450
Mailing Address - Fax:
Practice Address - Street 1:201 E RUDISILL BLVD STE 100B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1756
Practice Address - Country:US
Practice Address - Phone:260-615-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician