MEDICARE: REBA WILLIAMS JACOBS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide
2	372600000X	Adult Companion

General Provider Information

NPI Number	:	1962645424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBA WILLIAMS JACOBS

Provider Business Mailing Address
First Line	:	P.O.BOX 203
Second Line	:	15893 N.EDGEMONT DR.
City	:	DOLAN SPRINGS
State	:	AZ
Zip	:	86441
Country	:	US
Telephone Number	:	928-671-0709
Fax Number	:

Provider Business Practice Location Address
First Line	:	17160 N.MAGNOLIA DR.
Second Line	:
City	:	DOLAN SPRING
State	:	AZ
Zip	:	86441
Country	:	US
Telephone Number	:	928-767-3855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2009
Last Update Date	:	09/20/2009

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