Provider Demographics
NPI:1417531468
Name:MAGGARD, JACOB MICHAEL (PLMFT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:MAGGARD
Suffix:
Gender:M
Credentials:PLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18600 E 37TH TER S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1707
Mailing Address - Country:US
Mailing Address - Phone:816-200-7254
Mailing Address - Fax:
Practice Address - Street 1:18600 E 37TH TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1707
Practice Address - Country:US
Practice Address - Phone:816-200-7254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022036664106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2022036664OtherPLMFT LICENSE#