Provider Demographics
NPI:1215584735
Name:JACOBS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PARK LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94803-1220
Mailing Address - Country:US
Mailing Address - Phone:510-776-2928
Mailing Address - Fax:
Practice Address - Street 1:7567 AMADOR VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2441
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician