Provider Demographics
NPI:1427801471
Name:JACOBSON, SAMUEL COLE (OTRL)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:COLE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6861 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-1594
Mailing Address - Country:US
Mailing Address - Phone:248-895-3797
Mailing Address - Fax:
Practice Address - Street 1:43279 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1957
Practice Address - Country:US
Practice Address - Phone:313-278-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIZ3WA3DJZ225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty