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General NPI Number Information
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NPI Number | 1730719733
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Entity Type | Organization
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Legal Business Name | JACLYN E. JACOBS LLC
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Dates
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Enumeration Date | 01/19/2020
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Last Update Date | 01/19/2020
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Provider Practice Location Address
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Address Line | 401 S 2ND ST STE 401
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City | PHILADELPHIA
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State | PA
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Zip | 19147-1612
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Country | US
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Telephone | 267-388-0465
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 LOCUST ST APT 1515
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City | PHILADELPHIA
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State | PA
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Zip | 19102-4315
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Country | US
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Telephone | 304-549-4215
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JACLYN E JACOBS
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Credential | MS, CRC
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Telephone | 304-549-4215
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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