Provider Demographics
NPI:1790188589
Name:ORTIZ, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W 1ST ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5587
Mailing Address - Country:US
Mailing Address - Phone:775-332-8941
Mailing Address - Fax:
Practice Address - Street 1:900 W 1ST ST STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5587
Practice Address - Country:US
Practice Address - Phone:775-332-8941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVC-DAC I #01415I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)