Provider Demographics
NPI:1669053211
Name:KLIMOSKI, JACOB DARRALD (OTR/L)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:DARRALD
Last Name:KLIMOSKI
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6426 S WILSON ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3513
Mailing Address - Country:US
Mailing Address - Phone:602-573-4943
Mailing Address - Fax:
Practice Address - Street 1:4475 E KNOX RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-4848
Practice Address - Country:US
Practice Address - Phone:480-893-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-008393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty