Healthcare Provider Details

I. General information

NPI: 1457687816
Provider Name (Legal Business Name): BILL JACOBS LPCC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 ALAMEDA BLVD NW SUITE C
ALBUQUERQUE NM
87114-1240
US

IV. Provider business mailing address

8608 CLARIDGE PL NW SUITE C
ALBUQUERQUE NM
87114-6209
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-0810
  • Fax: 505-890-6806
Mailing address:
  • Phone: 505-379-0810
  • Fax: 505-890-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0065602
License Number StateNM

VIII. Authorized Official

Name: WILLIAM JACOBS
Title or Position: DIRECTOR
Credential: LPCC
Phone: 505-379-0810