=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619052826
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEA RENAE JACOBSON MPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 NE HOSTMARK ST SUITE 101
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-697-7726
-----------------------------------------------------
Fax | 360-677-7728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9621 RIDGETOP BLVD SUITE 100
-----------------------------------------------------
City | SILVERDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-337-7662
-----------------------------------------------------
Fax | 360-337-7300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 00010056
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------