Provider Demographics
NPI:1437656816
Name:JACOBS, SHANNA LEIGH
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEIGH
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 1:3801 KERN WAY
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-6340
Mailing Address - Country:US
Mailing Address - Phone:509-574-3200
Mailing Address - Fax:509-574-3210
Practice Address - Street 1:3801 KERN WAY
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-6340
Practice Address - Country:US
Practice Address - Phone:509-574-3200
Practice Address - Fax:509-574-3210
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WABA61367618103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor