Provider Demographics
NPI:1578188215
Name:JACOBS, DORA LENA (MPC, LCASA)
Entity Type:Individual
Prefix:MRS
First Name:DORA
Middle Name:LENA
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MPC, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3781
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-3781
Mailing Address - Country:US
Mailing Address - Phone:910-522-0408
Mailing Address - Fax:910-522-0465
Practice Address - Street 1:86 THREE HUNTS DRIVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372
Practice Address - Country:US
Practice Address - Phone:910-522-0408
Practice Address - Fax:910-522-0465
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21930101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)