Provider Demographics
NPI:1124299532
Name:JACOBS, MIRIAM JOY (JD, PHD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:JOY
Last Name:JACOBS
Suffix:
Gender:F
Credentials:JD, PHD
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8950 VILLA LA JOLLA DR
Mailing Address - Street 2:C-207
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1714
Mailing Address - Country:US
Mailing Address - Phone:858-534-8067
Mailing Address - Fax:
Practice Address - Street 1:8950 VILLA LA JOLLA DR
Practice Address - Street 2:C-207
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1714
Practice Address - Country:US
Practice Address - Phone:858-534-8067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21885103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical