Healthcare Provider Details

I. General information

NPI: 1376354845
Provider Name (Legal Business Name): JAKOB MARX C-SLPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 S GILBERT RD STE 105
MESA AZ
85204-6074
US

IV. Provider business mailing address

2646 N 22ND ST
MESA AZ
85213-1436
US

V. Phone/Fax

Practice location:
  • Phone: 480-765-4340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA15879
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: