Provider Demographics
NPI:1528170297
Name:JACOBSEN, TRACY (MA OTRL)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MA OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 855
Mailing Address - Street 2:
Mailing Address - City:WISNER
Mailing Address - State:NE
Mailing Address - Zip Code:68791
Mailing Address - Country:US
Mailing Address - Phone:402-529-3267
Mailing Address - Fax:
Practice Address - Street 1:2108 TAYLOR AVE
Practice Address - Street 2:SUITE 1100
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4641
Practice Address - Country:US
Practice Address - Phone:407-371-7545
Practice Address - Fax:402-379-0583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE460225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02429OtherBCBS
NEP00472371OtherRAILROAD MEDICARE
NEP00472371OtherRAILROAD MEDICARE
NEP00472371OtherRAILROAD MEDICARE