Provider Demographics
NPI:1952987190
Name:BOEHME, JACOB MITCHELL (DPT)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MITCHELL
Last Name:BOEHME
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S POWER RD STE 123
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-6688
Mailing Address - Country:US
Mailing Address - Phone:480-218-1344
Mailing Address - Fax:
Practice Address - Street 1:6021 S KINGS RANCH RD STE 5
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-4774
Practice Address - Country:US
Practice Address - Phone:480-982-7948
Practice Address - Fax:480-982-9145
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist