Provider Demographics
NPI:1093750655
Name:JACOBS, CAROLYN FRANCES (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:FRANCES
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5703
Mailing Address - Country:US
Mailing Address - Phone:619-525-7747
Mailing Address - Fax:619-476-7566
Practice Address - Street 1:625 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5703
Practice Address - Country:US
Practice Address - Phone:619-525-7747
Practice Address - Fax:619-476-7566
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15774103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP938AOtherMEDICARE PTAN
CA200742461OtherTIN