Provider Demographics
NPI:1962847095
Name:VOOGD, JACOB (MFTI)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:VOOGD
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:VOOGD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:205 PASADENA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2919
Mailing Address - Country:US
Mailing Address - Phone:323-344-5536
Mailing Address - Fax:
Practice Address - Street 1:205 PASADENA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030
Practice Address - Country:US
Practice Address - Phone:323-344-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT104865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7667OtherMEDI-CAL