Provider Demographics
NPI:1205015914
Name:JACOB, CAROL JOY (MA, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:JOY
Last Name:JACOB
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:JOY
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMHC
Mailing Address - Street 1:3307 174TH PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8532
Mailing Address - Country:US
Mailing Address - Phone:425-487-9369
Mailing Address - Fax:
Practice Address - Street 1:1129 W MAIN ST
Practice Address - Street 2:SUITE 194
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2034
Practice Address - Country:US
Practice Address - Phone:206-617-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010383101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health