Healthcare Provider Details

I. General information

NPI: 1457922429
Provider Name (Legal Business Name): JACOB TY PEHRSON LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 410
GLENDALE AZ
85308-8732
US

IV. Provider business mailing address

17505 N 79TH AVE STE 410
GLENDALE AZ
85308-8732
US

V. Phone/Fax

Practice location:
  • Phone: 623-800-7980
  • Fax:
Mailing address:
  • Phone: 623-800-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLAC-20054
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: