Provider Demographics
NPI:1780671057
Name:JACOBS, SCOTT L (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 DEXTER CT
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3494
Mailing Address - Country:US
Mailing Address - Phone:563-344-6645
Mailing Address - Fax:563-441-7796
Practice Address - Street 1:811 E LE CLAIRE RD
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:IA
Practice Address - Zip Code:52748-1733
Practice Address - Country:US
Practice Address - Phone:563-285-2174
Practice Address - Fax:563-285-5510
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02168225100000X
IL070005974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0221002Medicaid
IAI1931Medicare ID - Type Unspecified
IA0221002Medicaid