Provider Demographics
NPI:1346089745
Name:JACOBS, KATHLEEN BOURKE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BOURKE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6916 E MARIPOSA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-1220
Mailing Address - Country:US
Mailing Address - Phone:602-999-1190
Mailing Address - Fax:
Practice Address - Street 1:2400 W DUNLAP AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2813
Practice Address - Country:US
Practice Address - Phone:602-325-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician