Provider Demographics
NPI:1336574516
Name:JACOB, KIRSTEN (MAOM)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 W GRANT RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1474
Mailing Address - Country:US
Mailing Address - Phone:520-500-0535
Mailing Address - Fax:
Practice Address - Street 1:1955 W GRANT RD STE 150
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1474
Practice Address - Country:US
Practice Address - Phone:520-500-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000709171100000X
MDU02096171100000X
AZ0058612279P3900X
VA01170024132279P3900X
AZ10068171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics