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General NPI Number Information
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NPI Number | 1114753035
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Entity Type | Individual
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Provider Name | JAY D JACOBS
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Gender | Male
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Dates
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Enumeration Date | 09/09/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 105 CANYON LAKE CIR
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City | LUMBERTON
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State | TX
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Zip | 77657-3701
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Country | US
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Telephone | 409-200-2220
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Fax |
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Provider Business Mailing Address
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Address Line | 215 RUSTIC LN
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City | LUMBERTON
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State | TX
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Zip | 77657-6907
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Country | US
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Telephone | 409-549-3326
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Fax |
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 96392
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License Number State | TX
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