Healthcare Provider Details

I. General information

NPI: 1629461314
Provider Name (Legal Business Name): JOSEPH DANIEL JACOBS PHD, BCBA-D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/26/2023
Certification Date: 03/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12304 SANTA MONICA BLVD STE 315
LOS ANGELES CA
90025-2551
US

IV. Provider business mailing address

16350 VENTURA BLVD STE D147
ENCINO CA
91436-5300
US

V. Phone/Fax

Practice location:
  • Phone: 310-957-5126
  • Fax: 323-272-4076
Mailing address:
  • Phone: 310-957-5126
  • Fax: 818-654-6536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY33549
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33549
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: