Provider Demographics
NPI:1326259268
Name:JACOBS, JODY R (MTRS MED)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:R
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MTRS MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 OQUIRRH DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2036
Mailing Address - Country:US
Mailing Address - Phone:801-466-4141
Mailing Address - Fax:
Practice Address - Street 1:50 NORTH MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-339-9489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1026934001225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist