Basic Information
| Provider Information | |||||||||
| NPI: | 1376967570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | DUSTIN | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2523 28TH AVE S APT 2 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554063194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128606348 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3450 OLEARY LN | ||||||||
| Address2: | |||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551232340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514540114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2014 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.016078 | IL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 27099 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.