Provider Demographics
NPI:1578201745
Name:JACOBY, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JACOBY
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 1:5400 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-1662
Mailing Address - Country:US
Mailing Address - Phone:303-525-7658
Mailing Address - Fax:
Practice Address - Street 1:5400 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-1662
Practice Address - Country:US
Practice Address - Phone:303-525-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022013157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist