Healthcare Provider Details

I. General information

NPI: 1275463408
Provider Name (Legal Business Name): SYDNEY JACOBSON
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 GUERNSEY LN
RED WING MN
55066-7415
US

IV. Provider business mailing address

35319 63RD AVENUE WAY
CANNON FALLS MN
55009-7527
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-4441
  • Fax:
Mailing address:
  • Phone: 608-290-4234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number105472
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: