Basic Information
Provider Information | |||||||||
NPI: | 1295733954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACOBSEN | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | HAMDEN | ||||||||
State: | CT | ||||||||
PostalCode: | 06518 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2038656784 | ||||||||
FaxNumber: | 2038656788 | ||||||||
Practice Location | |||||||||
Address1: | 469 W MAIN ST | ||||||||
Address2: |   | ||||||||
City: | BRANFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 064053400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033156780 | ||||||||
FaxNumber: | 2033156788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251H1200X | 003272 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
ID Information
ID | Type | State | Issuer | Description | 1295733954 | 05 | CT |   | MEDICAID |