Basic Information
| Provider Information | |||||||||
| NPI: | 1740742956 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | BRE'ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CHINABERRY DR STE 903 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711112455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184596795 | ||||||||
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| Practice Location | |||||||||
| Address1: | 609 S VIENNA ST | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712705038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184551163 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2019 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.