Healthcare Provider Details

I. General information

NPI: 1215872288
Provider Name (Legal Business Name): JACOB DYLAN GOULD LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4030 CHOUTEAU AVE
SAINT LOUIS MO
63110-1754
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-657-3201
  • Fax:
Mailing address:
  • Phone: 844-853-8937
  • Fax: 660-885-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number2026015371
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: