Provider Demographics
NPI:1780812214
Name:JACOB, BRENDA LAVONNE (MS, CCDC III, LAT)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LAVONNE
Last Name:JACOB
Suffix:
Gender:F
Credentials:MS, CCDC III, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-7605
Mailing Address - Country:US
Mailing Address - Phone:307-689-0666
Mailing Address - Fax:
Practice Address - Street 1:113 S GILLETTE AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3740
Practice Address - Country:US
Practice Address - Phone:307-685-6982
Practice Address - Fax:307-685-8054
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLAT-270101YA0400X
SD99111065101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)