Provider Demographics
NPI:1366539207
Name:JACOBSEN, DEANNE YVONNE (MSPT)
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:YVONNE
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:DEANNE
Other - Middle Name:YVONNE
Other - Last Name:AUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2727 N GRANDVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2727 N GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6100
Practice Address - Country:US
Practice Address - Phone:414-333-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6111-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40385600Medicaid
WI40385600Medicaid