MEDICARE: JACOB KULP GOTWALS MA

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	LPC.0016856	CO
2	101YM0800X	Mental Health Counselor	CCMH0206221	NM
3	101YM0800X	Mental Health Counselor	LPC-21792	AZ
4	101YM0800X	Mental Health Counselor	TPMC1646	FL

General Provider Information

NPI Number	:	1831540210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB KULP GOTWALS MA

Provider Business Mailing Address
First Line	:	3355 N WILD DAISY PL
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85750-3139
Country	:	US
Telephone Number	:	505-336-0088
Fax Number	:

Provider Business Practice Location Address
First Line	:	3355 N WILD DAISY PL
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85750-3139
Country	:	US
Telephone Number	:	505-336-0088
Fax Number	:

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

Provider Enumeration Date	:	06/27/2016
Last Update Date	:	01/28/2026

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