Provider Demographics
NPI:1801117072
Name:ADAL, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ADAL
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:ADAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:16654 SOLEDAD CANYON RD STE 204
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-3217
Mailing Address - Country:US
Mailing Address - Phone:661-270-6644
Mailing Address - Fax:661-360-8440
Practice Address - Street 1:16654 SOLEDAD CANYON RD
Practice Address - Street 2:SUITE 204
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-3217
Practice Address - Country:US
Practice Address - Phone:661-270-6644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28617103TA0700X, 103TA0400X, 103TB0200X, 103TC1900X, 103TF0000X, 103TP2701X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954505783OtherCOMMUNITY MENTAL HEALTH