Provider Demographics
NPI:1467024075
Name:COSTA, JACOB THOMAS (MS, LMFT)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:THOMAS
Last Name:COSTA
Suffix:
Gender:M
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1396 REDONDO AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2885
Mailing Address - Country:US
Mailing Address - Phone:310-918-9581
Mailing Address - Fax:
Practice Address - Street 1:655 DEEP VALLEY DR STE 265
Practice Address - Street 2:
Practice Address - City:ROLLING HILLS ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-3620
Practice Address - Country:US
Practice Address - Phone:310-936-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty