Provider Demographics
NPI:1205313665
Name:EZELL, JACOB HENRY (LMSW)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:HENRY
Last Name:EZELL
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:MR
Other - First Name:JACOB
Other - Middle Name:HENRY
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-2235
Mailing Address - Country:US
Mailing Address - Phone:615-460-4200
Mailing Address - Fax:
Practice Address - Street 1:2400 WHITE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-2235
Practice Address - Country:US
Practice Address - Phone:615-460-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11771104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker