Provider Demographics
NPI:1295925642
Name:JACOBY, KINDRA K (PA)
Entity type:Individual
Prefix:
First Name:KINDRA
Middle Name:K
Last Name:JACOBY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 WEST RIVER PARK DR.
Mailing Address - Street 2:STE. #350
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-229-1014
Mailing Address - Fax:801-229-1067
Practice Address - Street 1:280 WEST RIVER PARK DR.
Practice Address - Street 2:STE. #350
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-229-1014
Practice Address - Fax:801-229-1067
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4992594-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical