Provider Demographics
NPI:1104427723
Name:JACOBS, TAD WESLEY
Entity type:Individual
Prefix:
First Name:TAD
Middle Name:WESLEY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:WESLEY
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1250 S 620 W # E1050
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-3326
Mailing Address - Country:US
Mailing Address - Phone:385-219-7352
Mailing Address - Fax:
Practice Address - Street 1:1250 S 620 W # E1050
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-3326
Practice Address - Country:US
Practice Address - Phone:385-219-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT219341047106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician