Healthcare Provider Details

I. General information

NPI: 1184810244
Provider Name (Legal Business Name): JACOB MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3628 STOCKDALE HWY
BAKERSFIELD CA
93309-2153
US

IV. Provider business mailing address

3628 STOCKDALE HWY
BAKERSFIELD CA
93309-2153
US

V. Phone/Fax

Practice location:
  • Phone: 661-322-1021
  • Fax:
Mailing address:
  • Phone: 661-322-1021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAMFT112693
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT143167
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: