Provider Demographics
NPI:1861548679
Name:JACOBO, LOURDES R (MD)
Entity type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:R
Last Name:JACOBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16950 N 49TH WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1082
Mailing Address - Country:US
Mailing Address - Phone:623-238-4284
Mailing Address - Fax:
Practice Address - Street 1:2120 CENTERPOINTE WEST DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-8487
Practice Address - Country:US
Practice Address - Phone:928-778-4581
Practice Address - Fax:928-776-1872
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ23974208000000X
AZ40096208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ401708Medicaid
AZ40096OtherLICENSE