Provider Demographics
NPI:1073909719
Name:WHITE, JACOB MATTHEW (MS LPC NCC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:WHITE
Suffix:
Gender:M
Credentials:MS LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 W MONROE AVE.
Mailing Address - Street 2:SUITE Q
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745
Mailing Address - Country:US
Mailing Address - Phone:479-320-7100
Mailing Address - Fax:
Practice Address - Street 1:213 W MONROE AVE
Practice Address - Street 2:SUITE Q
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9451
Practice Address - Country:US
Practice Address - Phone:479-320-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1503018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional