Provider Demographics
NPI:1700266434
Name:JACOBO, EDDIE
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:
Last Name:JACOBO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:EDDIE
Other - Middle Name:L
Other - Last Name:JACOBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BOCPO
Mailing Address - Street 1:2609 W BEVERLY BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2300
Mailing Address - Country:US
Mailing Address - Phone:909-342-8951
Mailing Address - Fax:
Practice Address - Street 1:2609 W BEVERLY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2300
Practice Address - Country:US
Practice Address - Phone:909-342-8951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC51396171W00000X, 1744P3200X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No171W00000XOther Service ProvidersContractor
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management