Healthcare Provider Details

I. General information

NPI: 1154921799
Provider Name (Legal Business Name): JACOB M BOUNDS MSW, LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 JEFFERSON RD STE C
SOUTH CHARLESTON WV
25309-8815
US

IV. Provider business mailing address

1234 STONE RD APT A
CHARLESTON WV
25314-1881
US

V. Phone/Fax

Practice location:
  • Phone: 877-338-2725
  • Fax:
Mailing address:
  • Phone: 304-989-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW062015550
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBP00945821
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: