Healthcare Provider Details

I. General information

NPI: 1376003236
Provider Name (Legal Business Name): JACOB W ABBAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 S PAGOSA BLVD
PAGOSA SPRINGS CO
81147-8329
US

IV. Provider business mailing address

95 S PAGOSA BLVD
PAGOSA SPRINGS CO
81147-8329
US

V. Phone/Fax

Practice location:
  • Phone: 970-731-3700
  • Fax: 970-731-0511
Mailing address:
  • Phone: 970-731-3700
  • Fax: 970-731-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0018706
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: