Provider Demographics
NPI:1386996866
Name:JACOBS, JACQUETTE (LCPC)
Entity type:Individual
Prefix:
First Name:JACQUETTE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 IRON HORSE LN
Mailing Address - Street 2:APT 121
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-2154
Mailing Address - Country:US
Mailing Address - Phone:240-468-8476
Mailing Address - Fax:
Practice Address - Street 1:9050 IRON HORSE LN
Practice Address - Street 2:APT 121
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-2154
Practice Address - Country:US
Practice Address - Phone:240-468-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4304101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health