Provider Demographics
NPI:1518300847
Name:JACOB, LAUREN BETTY (MA, TLLP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:BETTY
Last Name:JACOB
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:BETTY
Other - Last Name:GRUSHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, TLLP
Mailing Address - Street 1:2351 W. 12 MILE RD.
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1826
Mailing Address - Country:US
Mailing Address - Phone:248-544-4004
Mailing Address - Fax:248-544-4113
Practice Address - Street 1:2351 W. 12 MILE RD.
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1826
Practice Address - Country:US
Practice Address - Phone:248-544-4004
Practice Address - Fax:248-544-4113
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2310588103TC0700X
MI6301015300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical