Provider Demographics
NPI:1932541315
Name:MCBRIDE, JACOB KERRY (ACMHC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:KERRY
Last Name:MCBRIDE
Suffix:
Gender:M
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E 100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-428-3443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
UT10844181-6004101YM0800X
UT10844181-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No253J00000XAgenciesFoster Care Agency