Healthcare Provider Details

I. General information

NPI: 1720454721
Provider Name (Legal Business Name): THERESA JACOBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17637 WREN DR
CANYON COUNTRY CA
91387-3826
US

IV. Provider business mailing address

17637 WREN DR
CANYON COUNTRY CA
91387-3826
US

V. Phone/Fax

Practice location:
  • Phone: 818-485-0888
  • Fax:
Mailing address:
  • Phone: 310-654-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95029730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: