Provider Demographics
NPI:1598018335
Name:JACOBS, DORETTA
Entity Type:Individual
Prefix:
First Name:DORETTA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3581 LACKEY ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9048
Mailing Address - Country:US
Mailing Address - Phone:910-738-5023
Mailing Address - Fax:910-738-1581
Practice Address - Street 1:3581 LACKEY ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-9048
Practice Address - Country:US
Practice Address - Phone:910-738-5023
Practice Address - Fax:910-738-1581
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2743A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health