Provider Demographics
NPI:1639273758
Name:VANLEEUWEN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:VANLEEUWEN
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 1:690 N COFCO CENTER CT
Mailing Address - Street 2:STE 260
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-6462
Mailing Address - Country:US
Mailing Address - Phone:602-279-6905
Mailing Address - Fax:602-279-6934
Practice Address - Street 1:5757 W THUNDERBIRD RD
Practice Address - Street 2:SUITE E-465
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4641
Practice Address - Country:US
Practice Address - Phone:602-843-9945
Practice Address - Fax:602-843-8775
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2197225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ885676Medicaid
AZ885676Medicaid