Basic Information
| Provider Information | |||||||||
| NPI: | 1891012274 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 WOODSAGE LN | ||||||||
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| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134346 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1829 E FRANKLIN ST | ||||||||
| Address2: | BLG 600 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275145861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199683456 | ||||||||
| FaxNumber: | 9199323456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 11/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6701 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.