Provider Demographics
NPI:1205958980
Name:WICKENHEISER, JACOB BURTON (LCSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BURTON
Last Name:WICKENHEISER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:BURTON
Other - Last Name:WICKENHEISER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1526 WATERWHEEL DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1526 WATERWHEEL DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-2390
Practice Address - Country:US
Practice Address - Phone:510-703-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2022-09-22
Deactivation Date:2013-10-24
Deactivation Code:
Reactivation Date:2022-09-14
Provider Licenses
StateLicense IDTaxonomies
CA262971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical