Provider Demographics
NPI:1609572585
Name:JACOBS, RUSSELL JR
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:JACOBS
Suffix:JR
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 1:13820 VICTORY BLVD APT 206
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-2332
Mailing Address - Country:US
Mailing Address - Phone:267-496-6041
Mailing Address - Fax:
Practice Address - Street 1:16650 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3782
Practice Address - Country:US
Practice Address - Phone:818-901-4836
Practice Address - Fax:818-376-0044
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner