Provider Demographics
NPI:1801212444
Name:JACOBSON, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12919 WEXFORD PARK
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1401
Mailing Address - Country:US
Mailing Address - Phone:240-938-1128
Mailing Address - Fax:
Practice Address - Street 1:12919 WEXFORD PARK
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21029-1401
Practice Address - Country:US
Practice Address - Phone:240-938-1128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4076225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant