Provider Demographics
NPI:1396520417
Name:JACOBSEN, CHRISTIAN LYNN (PTA)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:LYNN
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 OBRIAN ST
Mailing Address - Street 2:
Mailing Address - City:GOOSE LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:52750-9650
Mailing Address - Country:US
Mailing Address - Phone:563-219-3358
Mailing Address - Fax:
Practice Address - Street 1:1301 MAYNARD WAY
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-9319
Practice Address - Country:US
Practice Address - Phone:563-221-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant