Healthcare Provider Details

I. General information

NPI: 1790154474
Provider Name (Legal Business Name): JUDY JACOBS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 E SPEEDWAY BLVD STE 6
TUCSON AZ
85719-4748
US

IV. Provider business mailing address

2450 E SPEEDWAY BLVD STE 6
TUCSON AZ
85719-4748
US

V. Phone/Fax

Practice location:
  • Phone: 928-254-8600
  • Fax:
Mailing address:
  • Phone: 928-254-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number6305
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUDY JACOBS
Title or Position: ACUPUNCTURIST
Credential: AC
Phone: 928-254-8600