Provider Demographics
NPI:1316784812
Name:UNDERWOOD, JACOB (MS, LPCC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 RALPHS RDG APT 205
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-4409
Mailing Address - Country:US
Mailing Address - Phone:615-582-3754
Mailing Address - Fax:
Practice Address - Street 1:1702 E PIKES PEAK AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5717
Practice Address - Country:US
Practice Address - Phone:719-344-9483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0020975101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health