Healthcare Provider Details

I. General information

NPI: 1063033827
Provider Name (Legal Business Name): DEANN MARIE JACOBSEN MS, PTA, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEANN MARIE PIAZZA

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8750 BRIARCLIFF LN
RIVERSIDE CA
92508-2519
US

IV. Provider business mailing address

8750 BRIARCLIFF LN
RIVERSIDE CA
92508-2519
US

V. Phone/Fax

Practice location:
  • Phone: 916-718-0775
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: