MEDICARE: TRAVIS JACOBS

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	101YM0800X	Mental Health Counselor	0704016636	VA

General Provider Information

NPI Number	:	1639007818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS JACOBS

Provider Business Mailing Address
First Line	:	5505 ALSON DR APT 161A
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-1541
Country	:	US
Telephone Number	:	336-686-2145
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 ALSON DR APT 161A
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-1541
Country	:	US
Telephone Number	:	336-686-2145
Fax Number	:

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

Provider Enumeration Date	:	05/11/2026
Last Update Date	:	05/11/2026

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