Provider Demographics
NPI:1629461314
Name:JACOBS, JOSEPH DANIEL (PHD, BCBA-D)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:DANIEL
Last Name:JACOBS
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16350 VENTURA BLVD STE D147
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5300
Mailing Address - Country:US
Mailing Address - Phone:310-957-5126
Mailing Address - Fax:818-654-6536
Practice Address - Street 1:12304 SANTA MONICA BLVD STE 315
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2551
Practice Address - Country:US
Practice Address - Phone:310-957-5126
Practice Address - Fax:323-272-4076
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2023-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
CAPSY33549103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR8889095Medicaid