Provider Demographics
NPI:1689047805
Name:JACOB, JEROME JR
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:JACOB
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PHOENIX FAMILY LIFE CENTERS, 100 ASMA BLVD, SUITE 200,
Mailing Address - Street 2:PHOENIX FAMILY LIFE CENTERS, 100 ASMA BLVD, SUITE 200,
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3221
Mailing Address - Country:US
Mailing Address - Phone:337-380-8947
Mailing Address - Fax:
Practice Address - Street 1:315 S COLLEGE RD STE 220
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-380-8947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006065417171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health