Provider Demographics
NPI:1811673692
Name:YANCEY, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:YANCEY
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 1:4881 NW 8TH AVENUE SUITE 1
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4881 NW 8TH AVENUE SUITE 1
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-474-8882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24153101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health