Basic Information
| Provider Information | |||||||||
| NPI: | 1699037671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E LAHARPE ST | ||||||||
| Address2: | |||||||||
| City: | KIRKSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6606651962 | ||||||||
| FaxNumber: | 6606653989 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 W DOUGLAS AVE | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672035455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3169432051 | ||||||||
| FaxNumber: | 3169432192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2012 | ||||||||
| LastUpdateDate: | 06/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 506 | KS | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.