Basic Information
| Provider Information | |||||||||
| NPI: | 1356900849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACOB LAWRENCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JACOB LAWRENCE LCSW LCAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 19 EPLEE LN | ||||||||
| Address2: | |||||||||
| City: | CANDLER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287156403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284589445 | ||||||||
| FaxNumber: | 8285441201 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 EPLEE LN | ||||||||
| Address2: | |||||||||
| City: | CANDLER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287156403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284589445 | ||||||||
| FaxNumber: | 8285441201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED INDIVIDUAL | ||||||||
| AuthorizedOfficialTelephone: | 8284589445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW, LCAS | ||||||||
| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.