Provider Demographics
NPI:1124536115
Name:WOOLEY, JACOB TOMMY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:TOMMY
Last Name:WOOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1201
Practice Address - Country:US
Practice Address - Phone:760-547-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-15-02750106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician