Healthcare Provider Details

I. General information

NPI: 1295327096
Provider Name (Legal Business Name): CURTIS LESLIE JACOBSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3784 SUMMIT RUN TRL
IDAHO FALLS ID
83404-8248
US

IV. Provider business mailing address

3784 SUMMIT RUN TRL
IDAHO FALLS ID
83404-8248
US

V. Phone/Fax

Practice location:
  • Phone: 208-731-9896
  • Fax:
Mailing address:
  • Phone: 208-731-9896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT-1675
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: