Provider Demographics
NPI:1588149017
Name:AMBROSE, JACOB J
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:AMBROSE
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 1:1110 24TH STREET
Mailing Address - Street 2:APT 8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2000
Mailing Address - Country:US
Mailing Address - Phone:619-728-4177
Mailing Address - Fax:573-503-0122
Practice Address - Street 1:1110 24TH ST
Practice Address - Street 2:APT 8
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102
Practice Address - Country:US
Practice Address - Phone:619-728-4177
Practice Address - Fax:573-503-0122
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34639103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical