Provider Demographics
NPI:1144323015
Name:JACOBSON, LATISHA MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:LATISHA
Middle Name:MARIE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 E. CRAWFORT ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SALINA
Mailing Address - State:KS
Mailing Address - Zip Code:67401-5116
Mailing Address - Country:US
Mailing Address - Phone:785-825-2323
Mailing Address - Fax:785-825-2325
Practice Address - Street 1:631 E. CRAWFORT ST
Practice Address - Street 2:SUITE 220
Practice Address - City:SALINA
Practice Address - State:KS
Practice Address - Zip Code:67401-5116
Practice Address - Country:US
Practice Address - Phone:785-825-2323
Practice Address - Fax:785-825-2325
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200003420AMedicaid
KS140563Medicare ID - Type Unspecified
KS200003420AMedicaid