Provider Demographics
NPI:1992250435
Name:JACOBSON, SUSAN (PT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JACOBSON
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 1:11510 CUSHMAN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3708
Mailing Address - Country:US
Mailing Address - Phone:301-770-6458
Mailing Address - Fax:
Practice Address - Street 1:5550 TUCKERMAN LN
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-4683
Practice Address - Country:US
Practice Address - Phone:301-579-4953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist