Provider Demographics
NPI:1750087573
Name:JACOBS, ADDIE LYN (MS, OTD, OTR)
Entity type:Individual
Prefix:DR
First Name:ADDIE
Middle Name:LYN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MS, OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 SHADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4710
Mailing Address - Country:US
Mailing Address - Phone:317-438-7191
Mailing Address - Fax:
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6910
Practice Address - Country:US
Practice Address - Phone:317-217-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006905A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist