Provider Demographics
NPI:1063815959
Name:WALDRON, JACOB LEE
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:LEE
Last Name:WALDRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:LEE
Other - Last Name:WALDRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3220 N 38TH ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6306
Mailing Address - Country:US
Mailing Address - Phone:815-514-0723
Mailing Address - Fax:
Practice Address - Street 1:7555 N PIMA RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4013
Practice Address - Country:US
Practice Address - Phone:815-514-0723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer