Provider Demographics
NPI:1548735079
Name:WHITE, JACOB VAUGHN (PHD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:VAUGHN
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 W. FRONT STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-750-7045
Mailing Address - Fax:
Practice Address - Street 1:3537 W. FRONT STREET
Practice Address - Street 2:SUITE F
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018202103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical