Provider Demographics
NPI:1063045458
Name:JACOBS, JUDY MICHELLE (MLSW CCTP1)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:MICHELLE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MLSW CCTP1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BULLARD
Mailing Address - Street 2:
Mailing Address - City:MANILA
Mailing Address - State:AR
Mailing Address - Zip Code:72442-8216
Mailing Address - Country:US
Mailing Address - Phone:870-484-0572
Mailing Address - Fax:870-486-2826
Practice Address - Street 1:103 BULLARD
Practice Address - Street 2:
Practice Address - City:MANILA
Practice Address - State:AR
Practice Address - Zip Code:72442-8216
Practice Address - Country:US
Practice Address - Phone:870-484-0572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9822-M1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical