Healthcare Provider Details

I. General information

NPI: 1912832684
Provider Name (Legal Business Name): JOSHUA JAKUBCZAK TLAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5513 W DEL RIO CT
CHANDLER AZ
85226-1880
US

IV. Provider business mailing address

5513 W DEL RIO CT
CHANDLER AZ
85226-1880
US

V. Phone/Fax

Practice location:
  • Phone: 602-905-5404
  • Fax:
Mailing address:
  • Phone: 602-905-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-08471T
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: