Provider Demographics
NPI:1609342344
Name:STRACENER, JACOB DANIEL (BA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:STRACENER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 WOODLAWN AVE APT 27
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5140
Mailing Address - Country:US
Mailing Address - Phone:619-730-9118
Mailing Address - Fax:
Practice Address - Street 1:8303 CLAIREMONT MESA BLVD STE 201202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1326
Practice Address - Country:US
Practice Address - Phone:949-401-0619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-20
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-67467106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician