Provider Demographics
NPI:1063570612
Name:JACOBSEN, JAN (OTR)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6055 MERIDIAN AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2700
Mailing Address - Country:US
Mailing Address - Phone:408-927-0871
Mailing Address - Fax:408-927-0891
Practice Address - Street 1:6055 MERIDIAN AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-2700
Practice Address - Country:US
Practice Address - Phone:408-927-0871
Practice Address - Fax:408-927-0891
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3894831225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3894831OtherCA OT LICENSE