Provider Demographics
NPI:1003645920
Name:JACOBO, LUIS ALEJANDRO (MS, ATC)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ALEJANDRO
Last Name:JACOBO
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3616 JENNY LIND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660-5610
Mailing Address - Country:US
Mailing Address - Phone:916-208-4144
Mailing Address - Fax:
Practice Address - Street 1:6385 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3713
Practice Address - Country:US
Practice Address - Phone:209-477-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000539282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer