Provider Demographics
NPI:1669165361
Name:JACOBSEN, ANDREW (DPT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 LAKE OTIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5234
Mailing Address - Country:US
Mailing Address - Phone:907-562-2277
Mailing Address - Fax:907-563-3460
Practice Address - Street 1:3125 E MERIDIAN PARK LOOP STE 300
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7528
Practice Address - Country:US
Practice Address - Phone:907-562-2277
Practice Address - Fax:907-563-3460
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK222447225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1751764Medicaid