Basic Information
| Provider Information | |||||||||
| NPI: | 1700946142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MBA, OTRL, C/NDT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11930 WHITMORE LAKE RD. | ||||||||
| Address2: | SUITE I-M | ||||||||
| City: | WHITMORE LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344494649 | ||||||||
| FaxNumber: | 7344494669 | ||||||||
| Practice Location | |||||||||
| Address1: | 11930 WHITMORE LAKE RD. | ||||||||
| Address2: | SUITE I-M | ||||||||
| City: | WHITMORE LAKE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344494649 | ||||||||
| FaxNumber: | 7344494669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 02/18/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 5201004063 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.