Provider Demographics
NPI:1770726739
Name:JACOB, KRYSTAL (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:PSYD
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 799
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95518-0799
Mailing Address - Country:US
Mailing Address - Phone:707-616-6147
Mailing Address - Fax:
Practice Address - Street 1:381 BAYSIDE RD STE B
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-7102
Practice Address - Country:US
Practice Address - Phone:707-616-6147
Practice Address - Fax:707-297-3035
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25790103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program