Provider Demographics
NPI:1295327096
Name:JACOBSON, CURTIS LESLIE (PT)
Entity type:Individual
Prefix:
First Name:CURTIS
Middle Name:LESLIE
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3784 SUMMIT RUN TRL
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8248
Mailing Address - Country:US
Mailing Address - Phone:208-731-9896
Mailing Address - Fax:
Practice Address - Street 1:3784 SUMMIT RUN TRL
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8248
Practice Address - Country:US
Practice Address - Phone:208-731-9896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-16752081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine