Provider Demographics
NPI:1184248916
Name:JACOBS, KALA (SSP)
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 CLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2516
Mailing Address - Country:US
Mailing Address - Phone:314-989-8150
Mailing Address - Fax:
Practice Address - Street 1:2901 TROOST AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1538
Practice Address - Country:US
Practice Address - Phone:816-418-4891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool