Provider Demographics
NPI:1821058231
Name:JACOBSEN, TINA MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 W ROSE CREST DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-1721
Mailing Address - Country:US
Mailing Address - Phone:605-357-3661
Mailing Address - Fax:
Practice Address - Street 1:606 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:BERESFORD
Practice Address - State:SD
Practice Address - Zip Code:57004-1125
Practice Address - Country:US
Practice Address - Phone:605-763-2048
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist