=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629960711
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACOB'S REHAB SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2025
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7104 MEADOW LAKE DR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-414-3007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7104 MEADOW LAKE DR
-----------------------------------------------------
City | YUKON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73099-6033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-414-3007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT/SECRETARY
-----------------------------------------------------
Name | AZARAYAH JAEL-DOVE ISRAEL
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 405-414-3007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------