Provider Demographics
NPI:1376388967
Name:KOZECKE, JACOB (LCSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KOZECKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1385
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:NC
Mailing Address - Zip Code:28124-1385
Mailing Address - Country:US
Mailing Address - Phone:704-280-3624
Mailing Address - Fax:
Practice Address - Street 1:5605 STATE HWY 49
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124
Practice Address - Country:US
Practice Address - Phone:704-280-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical