Provider Demographics
NPI:1396762332
Name:JACOBO PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:JACOBO PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:JACOBO
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:661-631-8793
Mailing Address - Street 1:2441 G ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2809
Mailing Address - Country:US
Mailing Address - Phone:661-631-8793
Mailing Address - Fax:661-631-9257
Practice Address - Street 1:2441 G ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2809
Practice Address - Country:US
Practice Address - Phone:661-631-8793
Practice Address - Fax:661-631-9257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14574261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT145740OtherBLUE SHIELD OF CAL NUMBER
CAPT0145740Medicaid
CA0PT145740Medicare UPIN
CAPT0145740Medicaid