Provider Demographics
NPI:1811200561
Name:JACOBSON, AMY LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNN
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 54TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3751
Mailing Address - Country:US
Mailing Address - Phone:712-540-7418
Mailing Address - Fax:
Practice Address - Street 1:7000 54TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3751
Practice Address - Country:US
Practice Address - Phone:712-540-7418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11412-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist