Provider Demographics
NPI:1295857894
Name:JACOBS, MITCH (LPC)
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6109 AVERILL WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-3312
Mailing Address - Country:US
Mailing Address - Phone:214-793-4446
Mailing Address - Fax:
Practice Address - Street 1:10300 N CENTRAL EXPY
Practice Address - Street 2:SUITE 290
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-8600
Practice Address - Country:US
Practice Address - Phone:214-793-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional