Healthcare Provider Details

I. General information

NPI: 1306133608
Provider Name (Legal Business Name): KIMBERLY ANN JACOB PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 S 21ST ST
COLORADO SPRINGS CO
80904-5123
US

IV. Provider business mailing address

P. O. BOX 77132
COLORADO SPRINGS CO
80970
US

V. Phone/Fax

Practice location:
  • Phone: 719-329-1774
  • Fax:
Mailing address:
  • Phone: 719-201-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number6841
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: