Provider Demographics
NPI:1790204451
Name:JACOBSON, JORDAN (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11847 TREEWIND CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-5272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606
Practice Address - Country:US
Practice Address - Phone:800-586-5336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer