Provider Demographics
NPI:1194001032
Name:WOOTTEN, JACOB J (BA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:WOOTTEN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10910 CLARKSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6106
Mailing Address - Country:US
Mailing Address - Phone:443-783-1773
Mailing Address - Fax:
Practice Address - Street 1:10910 CLARKSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6106
Practice Address - Country:US
Practice Address - Phone:443-783-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCER-195162-M4P1Q7103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty