Provider Demographics
NPI:1174540108
Name:JACOBO, GRACIELA CHRISTINE (RPT)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:CHRISTINE
Last Name:JACOBO
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 MOHAWK ST
Mailing Address - Street 2:APT 12
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1508
Mailing Address - Country:US
Mailing Address - Phone:661-332-3550
Mailing Address - Fax:
Practice Address - Street 1:2828 H ST
Practice Address - Street 2:SUITE F
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1900
Practice Address - Country:US
Practice Address - Phone:661-631-8793
Practice Address - Fax:661-631-9257
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT145740OtherBLUE SHIELD OF CAL NUMBER
CAPT0145740Medicaid
CA134237820OtherBLUE CROSS OF CAL NUMBER
CA0PT145740Medicare UPIN
CA134237820OtherBLUE CROSS OF CAL NUMBER