=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518278373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INGRID JACOBS PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2010
-----------------------------------------------------
Last Update Date | 03/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 E CENTER ST STE 333
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701-5349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-236-9813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 E. CENTER STREET, SUITE 333
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-236-9813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 10-11P
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------