MEDICARE: MRS. MARY BETH JACOBSON PTA

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	225200000X	Physical Therapy Assistant	#681-019	WI

General Provider Information

NPI Number	:	1992817928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY BETH JACOBSON PTA

Provider Business Mailing Address
First Line	:	E11016A GROTH RD
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951-9727
Country	:	US
Telephone Number	:	608-644-9082
Fax Number	:

Provider Business Practice Location Address
First Line	:	E11016A GROTH RD
Second Line	:
City	:	NORTH FREEDOM
State	:	WI
Zip	:	53951-9727
Country	:	US
Telephone Number	:	608-644-9082
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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