Provider Demographics
NPI:1972809986
Name:JACOBS, ASHLEY MAYCOCK (PT, DPT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MAYCOCK
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ESTHER
Other - Last Name:MAYCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:126 AVOCADO AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-943-8105
Practice Address - Fax:951-943-8106
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12245961OtherCAQH PROVIDER ID
CAFT681XMedicare PIN
CAFT681YMedicare PIN