Provider Demographics
NPI:1114358660
Name:JACOBS, TAMMY DEMETRIUS (LPCA, MA, NCC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:DEMETRIUS
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LPCA, MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 COVIL AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2683
Mailing Address - Country:US
Mailing Address - Phone:910-202-4270
Mailing Address - Fax:
Practice Address - Street 1:503 COVIL AVE STE 102
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2683
Practice Address - Country:US
Practice Address - Phone:910-202-4270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional