Healthcare Provider Details

I. General information

NPI: 1164264719
Provider Name (Legal Business Name): TISHA CHAVIS JACOBS LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7489 ROCKFISH RD
RAEFORD NC
28376-6131
US

IV. Provider business mailing address

236 KATIE BUIE RD
RED SPRINGS NC
28377-4600
US

V. Phone/Fax

Practice location:
  • Phone: 910-584-6739
  • Fax: 833-260-0543
Mailing address:
  • Phone: 706-304-8870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP022526
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: