Provider Demographics
NPI:1194001032
Name:WOOTTEN, JACOB J (BA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:WOOTTEN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 ROBIN HOOD TRL
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1686
Mailing Address - Country:US
Mailing Address - Phone:443-783-6955
Mailing Address - Fax:
Practice Address - Street 1:65 ROBIN HOOD TRL
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1686
Practice Address - Country:US
Practice Address - Phone:443-783-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor