Provider Demographics
NPI:1104284025
Name:JACOBSON, EMILY (DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 S MOORLAND RD
Mailing Address - Street 2:MOORLAND RESERVE HEALTH CENTER
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7401
Mailing Address - Country:US
Mailing Address - Phone:262-798-7200
Mailing Address - Fax:262-798-7201
Practice Address - Street 1:4805 S MOORLAND RD
Practice Address - Street 2:MOORLAND RESERVE HEALTH CENTER
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7401
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:262-798-7201
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13031-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104284025Medicaid