MEDICARE: JAN JACOBSEN OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	3894831	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3894831	OTHER	CA	CA OT LICENSE

General Provider Information

NPI Number	:	1063570612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAN JACOBSEN OTR

Provider Business Mailing Address
First Line	:	6055 MERIDIAN AVE STE 110
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95120-2700
Country	:	US
Telephone Number	:	408-927-0871
Fax Number	:	408-927-0891

Provider Business Practice Location Address
First Line	:	6055 MERIDIAN AVE STE 110
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95120-2700
Country	:	US
Telephone Number	:	408-927-0871
Fax Number	:	408-927-0891

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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