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General NPI Number Information
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NPI Number | 1609162239
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Entity Type | Organization
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Legal Business Name | INGRID JACOBS, PH.D., P.A.
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Dates
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Enumeration Date | 06/22/2011
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Last Update Date | 06/22/2011
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Provider Practice Location Address
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Address Line | 1 E CENTER ST STE 333
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City | FAYETTEVILLE
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State | AR
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Zip | 72701-5303
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Country | US
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Telephone | 479-236-9813
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Fax |
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Provider Business Mailing Address
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Address Line | 1 E CENTER ST STE 333
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City | FAYETTEVILLE
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State | AR
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Zip | 72701-5303
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | INGRID JACOBS
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Credential | PH.D.
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Telephone | 479-236-9813
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 10-11P
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License Number State | AR
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