Provider Demographics
NPI:1740583301
Name:SKELLY-BROWN, JACOB (MFT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SKELLY-BROWN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8404
Mailing Address - Country:US
Mailing Address - Phone:619-662-5418
Mailing Address - Fax:
Practice Address - Street 1:4660 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-8404
Practice Address - Country:US
Practice Address - Phone:619-662-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52327106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist