Provider Demographics
NPI:1154303659
Name:JACOBS, AMY MARIE (LMLP LCP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LMLP LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9333 EAST 21ST ST., NORTH
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2927
Mailing Address - Country:US
Mailing Address - Phone:316-634-4700
Mailing Address - Fax:316-634-4770
Practice Address - Street 1:9333 EAST 21ST ST., NORTH
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2927
Practice Address - Country:US
Practice Address - Phone:316-634-4700
Practice Address - Fax:316-634-4770
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0345103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral