Basic Information
| Provider Information | |||||||||
| NPI: | 1609486596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 ALEX LN | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253042952 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5722 CABIN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | DAWES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250547700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045955006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2020 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0004X | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0100X | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.