Provider Demographics
NPI:1750053260
Name:JACOBS, CRISTA LEIGH
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:LEIGH
Last Name:JACOBS
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 1:333 1ST STREET #A313
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-9074
Mailing Address - Country:US
Mailing Address - Phone:951-897-7840
Mailing Address - Fax:
Practice Address - Street 1:333 1ST STREET #A313
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-9074
Practice Address - Country:US
Practice Address - Phone:951-897-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-03
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19255171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A