Provider Demographics
NPI:1316443062
Name:JACOB, L'KENDRA
Entity type:Individual
Prefix:
First Name:L'KENDRA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:L'KENDRA
Other - Middle Name:N
Other - Last Name:WILRYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:609 WARHAWK WAY APT R1
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-3104
Mailing Address - Country:US
Mailing Address - Phone:337-764-5414
Mailing Address - Fax:
Practice Address - Street 1:229 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-4620
Practice Address - Country:US
Practice Address - Phone:337-764-5414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor