Provider Demographics
NPI:1710855606
Name:ACOSTA, JAKE THOMAS
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:THOMAS
Last Name:ACOSTA
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3268 RADCLIFFE RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4621
Mailing Address - Country:US
Mailing Address - Phone:805-857-4193
Mailing Address - Fax:
Practice Address - Street 1:2323 N MOORPARK RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3101
Practice Address - Country:US
Practice Address - Phone:805-495-7491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-23
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA158665106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist