=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346921137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB JOSEPH HAMMONDS TCADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2023
-----------------------------------------------------
Last Update Date | 07/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1629 MADISON AVE
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41011-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-814-2280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1570 SAINT ANTHONY DR
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41011-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-481-1424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 270117
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------