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General NPI Number Information
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NPI Number | 1255504791
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Entity Type | Organization
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Legal Business Name | LORAN C JACOBS JR PLLC
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Dates
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Enumeration Date | 04/04/2008
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Last Update Date | 04/04/2008
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Provider Practice Location Address
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Address Line | 807 S PONDEROSA ST
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City | PAYSON
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State | AZ
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Zip | 85541-5542
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Country | US
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Telephone | 602-273-6770
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Fax | 602-889-0489
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Provider Business Mailing Address
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Address Line | PO BOX 29211
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City | PHOENIX
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State | AZ
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Zip | 85038-9211
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Country | US
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Telephone | 602-273-6770
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Fax | 602-889-0489
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | LORAN C. JACOBS JR.
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Credential | CRNA
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Telephone | 602-273-6770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RN151239
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License Number State | AZ
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