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General NPI Number Information
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NPI Number | 1063045458
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Entity Type | Individual
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Provider Name | JUDY MICHELLE JACOBS MLSW CCTP1
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Gender | Female
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Dates
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Enumeration Date | 02/13/2020
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Last Update Date | 02/13/2020
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Provider Practice Location Address
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Address Line | 103 BULLARD
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City | MANILA
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State | AR
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Zip | 72442-8216
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Country | US
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Telephone | 870-484-0572
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Fax |
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Provider Business Mailing Address
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Address Line | 103 BULLARD
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City | MANILA
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State | AR
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Zip | 72442-8216
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Country | US
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Telephone | 870-484-0572
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Fax | 870-486-2826
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 9822-M
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License Number State | AR
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