Healthcare Provider Details

I. General information

NPI: 1730889817
Provider Name (Legal Business Name): JACOBS PSYCHOLOGICAL SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/26/2023
Certification Date: 03/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

16350 VENTURA BLVD # D147
ENCINO CA
91436-5300
US

V. Phone/Fax

Practice location:
  • Phone: 818-571-2285
  • Fax: 323-272-4076
Mailing address:
  • Phone: 818-571-2285
  • Fax: 323-272-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOSEPH D JACOBS
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 818-571-2285