Provider Demographics
NPI:1770842114
Name:AMY M.JACOBS, LLC
Entity Type:Organization
Organization Name:AMY M.JACOBS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:316-636-1188
Mailing Address - Street 1:7807 E FUNSTON ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-3123
Mailing Address - Country:US
Mailing Address - Phone:316-636-1188
Mailing Address - Fax:
Practice Address - Street 1:7807 E FUNSTON ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-3123
Practice Address - Country:US
Practice Address - Phone:316-636-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS188251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1154303659OtherINDIVIDUAL NPI