Provider Demographics
NPI:1114176039
Name:JACOBS, GREG (LICDC)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1240
Mailing Address - Country:US
Mailing Address - Phone:419-222-1168
Mailing Address - Fax:419-222-2158
Practice Address - Street 1:530 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1240
Practice Address - Country:US
Practice Address - Phone:419-222-1168
Practice Address - Fax:419-222-2158
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH892563101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)