Provider Demographics
NPI:1598981185
Name:JACOBS, ELLEN RACHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:RACHAEL
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 FERN GLN
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5419
Mailing Address - Country:US
Mailing Address - Phone:858-459-5132
Mailing Address - Fax:
Practice Address - Street 1:7734 HERSCHEL AVE
Practice Address - Street 2:STE E
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4433
Practice Address - Country:US
Practice Address - Phone:858-459-6341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11462103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical