Provider Demographics
NPI:1154921799
Name:BOUNDS, JACOB M (MSW, LGSW)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:M
Last Name:BOUNDS
Suffix:
Gender:M
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 STONE RD APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1881
Mailing Address - Country:US
Mailing Address - Phone:304-989-1290
Mailing Address - Fax:
Practice Address - Street 1:1109 JEFFERSON RD STE C
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8815
Practice Address - Country:US
Practice Address - Phone:877-338-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
WVSW0620155501041C0700X
WVBP009458211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)