Basic Information
| Provider Information | |||||||||
| NPI: | 1770112799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIGHTNER | ||||||||
| OtherFirstName: | KRISTINE | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 150 KATHRYN DR | ||||||||
| Address2: | |||||||||
| City: | NEW BLOOMFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170688645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176092890 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25 E MCCLURE ST | ||||||||
| Address2: | |||||||||
| City: | NEW BLOOMFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170689334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177980383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2020 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC009183 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.