Provider Demographics
NPI:1083491575
Name:QUALLS, JACOB MARSHALL (LCADC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MARSHALL
Last Name:QUALLS
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1154
Mailing Address - Country:US
Mailing Address - Phone:859-287-1098
Mailing Address - Fax:
Practice Address - Street 1:1300 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1154
Practice Address - Country:US
Practice Address - Phone:859-287-1098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY299921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)