Provider Demographics
NPI:1790278398
Name:ESCOBEDO, JACOB ANTHONY
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:ANTHONY
Last Name:ESCOBEDO
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:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-0523
Mailing Address - Country:US
Mailing Address - Phone:951-218-4759
Mailing Address - Fax:
Practice Address - Street 1:3924 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:JURUPA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92509-6611
Practice Address - Country:US
Practice Address - Phone:951-416-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA894011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health