Healthcare Provider Details

I. General information

NPI: 1467370759
Provider Name (Legal Business Name): HEATHER JACOBSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22409 CANTARA ST
WEST HILLS CA
91304-3728
US

IV. Provider business mailing address

1968 S COAST HWY STE 821
LAGUNA BEACH CA
92651-3681
US

V. Phone/Fax

Practice location:
  • Phone: 929-645-1216
  • Fax:
Mailing address:
  • Phone: 929-645-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95037427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: