Provider Demographics
NPI:1497585830
Name:FONTES, JACOB JOSEPH (MA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:JOSEPH
Last Name:FONTES
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8696 SONGBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:HILMAR
Mailing Address - State:CA
Mailing Address - Zip Code:95324-9795
Mailing Address - Country:US
Mailing Address - Phone:209-485-1189
Mailing Address - Fax:
Practice Address - Street 1:1305 E VINE ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3148
Practice Address - Country:US
Practice Address - Phone:209-331-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC13232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health