Provider Demographics
NPI:1760701023
Name:EIDE, JACOB ANDREW (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANDREW
Last Name:EIDE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-924-4333
Mailing Address - Fax:
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-924-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical