Provider Demographics
NPI:1376882696
Name:JACOBS, JUDY GAIL
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:GAIL
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 1:619 WILLIS AVENUE
Mailing Address - Street 2:BOGALUSA MENTAL HEALTH CENTER
Mailing Address - City:BOGALUSA
Mailing Address - State:LA
Mailing Address - Zip Code:70427
Mailing Address - Country:US
Mailing Address - Phone:985-732-6610
Mailing Address - Fax:985-732-6626
Practice Address - Street 1:619 WILLIS AVENUE
Practice Address - Street 2:BOGALUSA MENTAL HEALTH CENTER
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427
Practice Address - Country:US
Practice Address - Phone:985-732-6610
Practice Address - Fax:985-732-6626
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA#910203164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse