Basic Information
| Provider Information | |||||||||
| NPI: | 1538134127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805389071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244323 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4650 SIGNAL TREE DR STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TIMNATH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805474908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702377415 | ||||||||
| FaxNumber: | 9702377420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 2435 | CO | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 29277523 | 05 | CO | MEDICAID | 11605559 | 01 | CO | CAQH PIN | OTHER | PSY.0002435 | 01 | CO | PROFESSIONAL LICENSE | OTHER |