Provider Demographics
NPI:1427745512
Name:GOMEZ, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12790 FM 1560 N UNIT 680
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-2229
Mailing Address - Country:US
Mailing Address - Phone:210-530-1180
Mailing Address - Fax:210-201-1190
Practice Address - Street 1:12274 BANDERA RD STE 120
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4386
Practice Address - Country:US
Practice Address - Phone:210-530-1180
Practice Address - Fax:210-201-1190
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88504101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor