Provider Demographics
NPI:1417292277
Name:JACOBS, GARY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 522
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89024-0522
Mailing Address - Country:US
Mailing Address - Phone:208-964-6441
Mailing Address - Fax:
Practice Address - Street 1:340 FALCON RIDGE PKWY
Practice Address - Street 2:BUILDING 500
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-8850
Practice Address - Country:US
Practice Address - Phone:702-346-3105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1409235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist