Healthcare Provider Details

I. General information

NPI: 1578531836
Provider Name (Legal Business Name): BETH JEAN JACOBSON PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR BLDG 3, SUITE 461
LA MESA CA
91942-3020
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BLDG 3, SUITE 461
LA MESA CA
91942-3020
US

V. Phone/Fax

Practice location:
  • Phone: 619-589-0850
  • Fax: 619-589-0878
Mailing address:
  • Phone: 619-589-0850
  • Fax: 619-589-0878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT8986
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT8986
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberPT8986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: