Provider Demographics
NPI:1245246503
Name:JACOB, SUSAN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:JACOB
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1101 DOVE ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2839
Mailing Address - Country:US
Mailing Address - Phone:949-851-5022
Mailing Address - Fax:949-851-5123
Practice Address - Street 1:1101 DOVE ST
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2839
Practice Address - Country:US
Practice Address - Phone:949-851-5022
Practice Address - Fax:949-851-5123
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAMFT25105101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional