Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 3501 | CO |
NPI | 1568599959 |
---|---|
Provider Name | Randy Jay Jacobs |
First Address | Conifer, CO 80433 |
Second Address | Conifer, CO 80433-7262 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 08/07/2007 |