Provider Demographics
NPI:1689099186
Name:SEIDEL, JACOB DAVID (LPC-MH)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:SEIDEL
Suffix:
Gender:M
Credentials:LPC-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 SAINT JOSEPH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2778
Mailing Address - Country:US
Mailing Address - Phone:605-721-0200
Mailing Address - Fax:605-721-0165
Practice Address - Street 1:731 SAINT JOSEPH ST STE 205
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2778
Practice Address - Country:US
Practice Address - Phone:605-721-0200
Practice Address - Fax:605-721-0165
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH20319101YP2500X
SDLPC7367101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2013890Medicaid
WY1689099186Medicaid