Provider Demographics
NPI:1942835665
Name:JACOBS, BRIANNA KAITLIN
Entity Type:Individual
Prefix:MRS
First Name:BRIANNA
Middle Name:KAITLIN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-4948
Mailing Address - Country:US
Mailing Address - Phone:336-455-1305
Mailing Address - Fax:
Practice Address - Street 1:5 CENTERVIEW DR STE 110
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3709
Practice Address - Country:US
Practice Address - Phone:336-455-1305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15585101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health