Provider Demographics
NPI:1093213654
Name:JACOB, DIANE (LCMHCA)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-5475
Mailing Address - Country:US
Mailing Address - Phone:239-560-5226
Mailing Address - Fax:
Practice Address - Street 1:1709 LEGION RD STE 211
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-2374
Practice Address - Country:US
Practice Address - Phone:239-560-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13549101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty