Provider Demographics
NPI:1902020761
Name:ANDERSON, JACOB CHRISTIAN (MSOTRL)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:CHRISTIAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NOBLES LN
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1627
Mailing Address - Country:US
Mailing Address - Phone:207-423-8244
Mailing Address - Fax:
Practice Address - Street 1:301 NOBLES LN
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-1627
Practice Address - Country:US
Practice Address - Phone:207-423-8244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1828225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist