Provider Demographics
NPI:1053053553
Name:THOMAS, JACOB GERALD
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:GERALD
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 N BELRIDGE TER
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-7404
Mailing Address - Country:US
Mailing Address - Phone:805-708-5816
Mailing Address - Fax:
Practice Address - Street 1:3050 SATURN ST STE 102
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6281
Practice Address - Country:US
Practice Address - Phone:657-444-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician