Provider Demographics
NPI:1497415475
Name:MEDFORD, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MEDFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44276 W NEELY DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-9427
Mailing Address - Country:US
Mailing Address - Phone:619-708-1440
Mailing Address - Fax:
Practice Address - Street 1:1204 E BASELINE RD STE 205
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1453
Practice Address - Country:US
Practice Address - Phone:619-708-1440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)