Provider Demographics
NPI:1508452491
Name:JACOBY, DEBORAH JEAN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:JACOBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 W PINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-4850
Mailing Address - Country:US
Mailing Address - Phone:208-608-6114
Mailing Address - Fax:
Practice Address - Street 1:115 W WILLOWAY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5937
Practice Address - Country:US
Practice Address - Phone:208-345-6625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251E00000X
311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251E00000XAgenciesHome Health