Provider Demographics
NPI:1508219890
Name:JACOBS, TAYLOR (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 INDIAN LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3057
Mailing Address - Country:US
Mailing Address - Phone:307-438-1039
Mailing Address - Fax:
Practice Address - Street 1:125 INDIAN LOOKOUT DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3057
Practice Address - Country:US
Practice Address - Phone:307-438-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1-15-19964103K00000X
WYPTSB63527103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist