Provider Demographics
NPI:1104434406
Name:ALBERTS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ALBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39555 ORCHARD HILL PLACE
Practice Address - Street 2:SUITE 600
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375
Practice Address - Country:US
Practice Address - Phone:248-599-1582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician