Healthcare Provider Details

I. General information

NPI: 1356217350
Provider Name (Legal Business Name): JACOB'S PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 W BULLARD AVE STE 107-110
CLOVIS CA
93612-0946
US

IV. Provider business mailing address

80 W BULLARD AVE STE 107-110
CLOVIS CA
93612-0946
US

V. Phone/Fax

Practice location:
  • Phone: 559-999-8341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER REYES
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-499-3861