Healthcare Provider Details

I. General information

NPI: 1700553054
Provider Name (Legal Business Name): JACOB WEBER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1884 22ND ST NW
ROCHESTER MN
55901-0618
US

IV. Provider business mailing address

1884 22ND ST NW
ROCHESTER MN
55901-0618
US

V. Phone/Fax

Practice location:
  • Phone: 651-422-8853
  • Fax: 651-348-8349
Mailing address:
  • Phone: 651-422-8853
  • Fax: 651-348-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC05020
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number111708
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: