Healthcare Provider Details

I. General information

NPI: 1689531196
Provider Name (Legal Business Name): JORDAN SIMON ZACK JACOBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TURNBERRY WAY
PINEHURST NC
28374-8508
US

IV. Provider business mailing address

8050 ARABIA RD
LUMBER BRIDGE NC
28357-8994
US

V. Phone/Fax

Practice location:
  • Phone: 704-440-3580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number000042338349
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: