Basic Information
| Provider Information | |||||||||
| NPI: | 1972809986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | MAYCOCK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAYCOCK | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | ESTHER | ||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 24630 WASHINGTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925626177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516969353 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 AVOCADO AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925712605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519438105 | ||||||||
| FaxNumber: | 9519438106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 36670 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 12245961 | 01 | CA | CAQH PROVIDER ID | OTHER |