Provider Demographics
NPI:1447476775
Name:JACOBS, KEN R (PT,MA)
Entity type:Individual
Prefix:MR
First Name:KEN
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PT,MA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18719 N BASE CAMP RD
Mailing Address - Street 2:HART PRAIRIE
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-9377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3285 E SPARROW AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7794
Practice Address - Country:US
Practice Address - Phone:928-627-6163
Practice Address - Fax:928-527-6181
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1131OtherSTATE BOARD LICENSE