MEDICARE: TAMARA JACOBS P.T.

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	225100000X	Physical Therapist	PT24108	FL

General Provider Information

NPI Number	:	1063790012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA JACOBS P.T.

Provider Business Mailing Address
First Line	:	1771 EDGEWOOD AVE W STE 6B
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3278
Country	:	US
Telephone Number	:	904-768-9966
Fax Number	:	904-765-1655

Provider Business Practice Location Address
First Line	:	1771 EDGEWOOD AVE W STE 6B
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3278
Country	:	US
Telephone Number	:	904-768-9966
Fax Number	:	904-765-1655

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

Provider Enumeration Date	:	07/25/2011
Last Update Date	:	07/25/2011

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