Provider Demographics
NPI:1205535044
Name:JACOBS, THYRA ANN (MA, ATR-BC, LPC)
Entity type:Individual
Prefix:
First Name:THYRA
Middle Name:ANN
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MA, ATR-BC, LPC
Other - Prefix:
Other - First Name:THYRA
Other - Middle Name:ANN
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-2428
Mailing Address - Country:US
Mailing Address - Phone:412-720-7565
Mailing Address - Fax:
Practice Address - Street 1:716 CAMBRIA ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-1700
Practice Address - Country:US
Practice Address - Phone:814-509-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC015203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional