Healthcare Provider Details

I. General information

NPI: 1700406477
Provider Name (Legal Business Name): MICHAEL PESCATORE JACOBSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 E HIGHLAND AVE STE 335
PHOENIX AZ
85016-4760
US

IV. Provider business mailing address

2122 E HIGHLAND AVE STE 335
PHOENIX AZ
85016-4760
US

V. Phone/Fax

Practice location:
  • Phone: 602-824-8404
  • Fax:
Mailing address:
  • Phone: 602-824-8404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006734RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: