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NPI Code Detail

MEDICARE: JACOB ERICKSON MT-BC

MEDICARE: JACOB ERICKSON MT-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1942673181
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB ERICKSON MT-BC
Provider Business Mailing Address
First Line : 4220 N GRAND BLVD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63107-1831
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4220 N GRAND BLVD
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63107-1831
Country : US
Telephone Number : 314-534-6624
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/10/2015
Last Update Date : 11/10/2015

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Directions to “ JACOB ERICKSON MT-BC” Practice Location

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