Provider Demographics
NPI:1477272797
Name:OTTMAN, JACOB S (LCMHCA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:S
Last Name:OTTMAN
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ESSEN PL
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8332
Mailing Address - Country:US
Mailing Address - Phone:202-823-2139
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9305
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA17819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health