Provider Demographics
NPI:1881484426
Name:JACOBSON, TIMOTHY G
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:JACOBSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-3959
Mailing Address - Country:US
Mailing Address - Phone:319-239-2955
Mailing Address - Fax:
Practice Address - Street 1:701 LORRAINE AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-3959
Practice Address - Country:US
Practice Address - Phone:319-239-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA259DD3969172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver