Provider Demographics
NPI:1811584451
Name:JACOBO, MARYLOU (CNA)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:JACOBO
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 N CAVE CREEK RD LOT 306
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1601
Mailing Address - Country:US
Mailing Address - Phone:623-258-7712
Mailing Address - Fax:
Practice Address - Street 1:10401 N CAVE CREEK RD LOT 306
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1601
Practice Address - Country:US
Practice Address - Phone:623-258-7712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1000026769376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide