Provider Demographics
NPI:1043925241
Name:JACOBSON, WESTON (ATC, MAT)
Entity type:Individual
Prefix:MR
First Name:WESTON
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:ATC, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-3505
Mailing Address - Country:US
Mailing Address - Phone:928-322-5587
Mailing Address - Fax:
Practice Address - Street 1:260 N DIXIE DR UNIT 535
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-6329
Practice Address - Country:US
Practice Address - Phone:928-322-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZATR-0095742255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer