Provider Demographics
NPI:1245984186
Name:JACOBS, ELYSSA E
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:E
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 LINDLEY AVE UNIT 207
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1918
Mailing Address - Country:US
Mailing Address - Phone:818-267-4020
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1486
Practice Address - Country:US
Practice Address - Phone:818-996-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA923441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical