Healthcare Provider Details

I. General information

NPI: 1689099186
Provider Name (Legal Business Name): JACOB DAVID SEIDEL LPC-MH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 SAINT JOSEPH ST STE 205
RAPID CITY SD
57701-2778
US

IV. Provider business mailing address

731 SAINT JOSEPH ST STE 205
RAPID CITY SD
57701-2778
US

V. Phone/Fax

Practice location:
  • Phone: 605-721-0200
  • Fax: 605-721-0165
Mailing address:
  • Phone: 605-721-0200
  • Fax: 605-721-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-MH20319
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2013890
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: