Provider Demographics
NPI:1710550124
Name:JACOBO, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:JACOBO
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 1:23521 PASEO DE VALENCIA
Mailing Address - Street 2:SUITE B7
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3125
Mailing Address - Country:US
Mailing Address - Phone:949-597-0007
Mailing Address - Fax:949-597-0040
Practice Address - Street 1:24582 DEL PRADO
Practice Address - Street 2:SUITE C
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3125
Practice Address - Country:US
Practice Address - Phone:949-276-5401
Practice Address - Fax:949-276-5403
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMT44882225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist