Doctor Name: | SHELLY A JACOBS |
NPI Number: | 1073532552 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | L.P.A. |
License Number: | 411 |
Business Practice Address: | 1700 Bogard Rd Suite 201 Wasilla, AK - 996546533 |
Business Phone Number: | 9073738080 |
Business Fax Number: | 9073738081 |
Mailing Address: | Po Box 4105, PORTLAND |
State: | OR |
Postal Code: | 972084105 |
Phone Number: | 8669071068 |
Fax Number: | 4259179141 |
NPI Enumeration Date: | 07/18/2006 |
NPI Last Update Date: | 04/13/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 411 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | AK |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |