Individual
KENNY JACOBS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
8010 W HILTON AVE, PHOENIX, AZ 85043-7420
(623) 322-5288
Mailing address
8010 W HILTON AVE, PHOENIX, AZ 85043-7420
(623) 322-5288
Taxonomy
Speciality
Code
Description
License number
State
385HR2055X
Child Mental Illness Respite Care
Primary
10730
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
113609
AHCCCS ID NUMBER
AZ
Enumeration date
11/20/2006
Last updated
07/08/2007
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