Provider Demographics
NPI:1063753671
Name:JACOBS, MICHAEL LEE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 HILL ST
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-7725
Mailing Address - Country:US
Mailing Address - Phone:401-823-6724
Mailing Address - Fax:
Practice Address - Street 1:1150 RESERVOIR AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6068
Practice Address - Country:US
Practice Address - Phone:401-942-2625
Practice Address - Fax:401-942-3097
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist