Provider Demographics
NPI:1871915520
Name:JACOBSON, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 E 200 N
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4707
Mailing Address - Country:US
Mailing Address - Phone:801-829-8823
Mailing Address - Fax:
Practice Address - Street 1:159 E 200 N
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4707
Practice Address - Country:US
Practice Address - Phone:801-829-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8827724-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist