Healthcare Provider Details

I. General information

NPI: 1255504791
Provider Name (Legal Business Name): LORAN C JACOBS JR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S PONDEROSA ST
PAYSON AZ
85541-5542
US

IV. Provider business mailing address

PO BOX 29211
PHOENIX AZ
85038-9211
US

V. Phone/Fax

Practice location:
  • Phone: 602-273-6770
  • Fax: 602-889-0489
Mailing address:
  • Phone: 602-273-6770
  • Fax: 602-889-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN151239
License Number StateAZ

VIII. Authorized Official

Name: LORAN C. JACOBS JR.
Title or Position: SOLE MEMBER
Credential: CRNA
Phone: 602-273-6770