MEDICARE: DOLORES P, JACOBY M.S.W., D. DIV,PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	604151293	WA
2	101YP1600X	Pastoral Counselor	604151293

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	604151293	OTHER	WA	TRIWEST, VETERAN'S ADMINISTRATION
2	604151293	OTHER	WA	VETERAN'S ADMINISTRATION

General Provider Information

NPI Number	:	1336667922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOLORES P, JACOBY M.S.W., D. DIV,PH.D.

Provider Business Mailing Address
First Line	:	716 VAN BUREN ST
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-8051
Country	:	US
Telephone Number	:	561-385-8420
Fax Number	:

Provider Business Practice Location Address
First Line	:	716 VAN BUREN ST
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-8051
Country	:	US
Telephone Number	:	561-385-8420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2017
Last Update Date	:	07/21/2022

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