Individual
MR. KEN R JACOBS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PT,MA
Contact information
Practice address
3285 E SPARROW AVE, FLAGSTAFF, AZ 86004-7794
(928) 627-6163
(928) 527-6181
Mailing address
18719 N BASE CAMP RD, HART PRAIRIE, FLAGSTAFF, AZ 86001-9377
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1131
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1131
STATE BOARD LICENSE
AZ
Enumeration date
04/17/2007
Last updated
07/08/2007
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