Healthcare Provider Details

I. General information

NPI: 1962645424
Provider Name (Legal Business Name): REBA WILLIAMS JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 09/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17160 N.MAGNOLIA DR.
DOLAN SPRING AZ
86441
US

IV. Provider business mailing address

P.O.BOX 203 15893 N.EDGEMONT DR.
DOLAN SPRINGS AZ
86441
US

V. Phone/Fax

Practice location:
  • Phone: 928-767-3855
  • Fax:
Mailing address:
  • Phone: 928-671-0709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: