Provider Demographics
NPI:1790059046
Name:JACOBS, CHEQUITTA (BSW)
Entity Type:Individual
Prefix:
First Name:CHEQUITTA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:CHEQUITTA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSW
Mailing Address - Street 1:3643 WALTON WAY EXT
Mailing Address - Street 2:BLDG 4
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4507
Mailing Address - Country:US
Mailing Address - Phone:706-364-1404
Mailing Address - Fax:706-364-1419
Practice Address - Street 1:3643 WALTON WAY EXT
Practice Address - Street 2:BLDG 4
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4507
Practice Address - Country:US
Practice Address - Phone:706-364-1404
Practice Address - Fax:706-364-1419
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker