Provider Demographics
NPI:1063418952
Name:JACOBSON, LEE DUANE (PT)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:DUANE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8455 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5066
Mailing Address - Country:US
Mailing Address - Phone:352-465-5880
Mailing Address - Fax:352-465-5889
Practice Address - Street 1:20726 W PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34431-6717
Practice Address - Country:US
Practice Address - Phone:352-465-5880
Practice Address - Fax:352-465-5889
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist