Provider Demographics
NPI:1235167552
Name:JACOBS, SARA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 MALVERN AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1405
Mailing Address - Country:US
Mailing Address - Phone:626-806-1165
Mailing Address - Fax:626-445-4350
Practice Address - Street 1:440 E HUNTINGTON DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-3776
Practice Address - Country:US
Practice Address - Phone:626-445-4222
Practice Address - Fax:626-445-4350
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29526225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29526AMedicare ID - Type Unspecified