Provider Demographics
NPI:1568004067
Name:JACOBE, DIVINA CECILIA ABALONA
Entity Type:Individual
Prefix:
First Name:DIVINA CECILIA
Middle Name:ABALONA
Last Name:JACOBE
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 1:3213 W CHARLESTON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1991
Mailing Address - Country:US
Mailing Address - Phone:702-767-3177
Mailing Address - Fax:702-570-6234
Practice Address - Street 1:3213 W CHARLESTON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1991
Practice Address - Country:US
Practice Address - Phone:702-767-3177
Practice Address - Fax:702-570-6234
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOT-2252225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist