Provider Demographics
NPI:1063790012
Name:JACOBS, TAMARA (PT)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 EDGEWOOD AVE W STE 6B
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3278
Mailing Address - Country:US
Mailing Address - Phone:904-768-9966
Mailing Address - Fax:904-765-1655
Practice Address - Street 1:1771 EDGEWOOD AVE W STE 6B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3278
Practice Address - Country:US
Practice Address - Phone:904-768-9966
Practice Address - Fax:904-765-1655
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT24108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist