Provider Demographics
NPI:1811318686
Name:SMYTH, JACOB (MFT IT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SMYTH
Suffix:
Gender:M
Credentials:MFT IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29085 COUNTY HWY W
Mailing Address - Street 2:
Mailing Address - City:HOLCOMBE
Mailing Address - State:WI
Mailing Address - Zip Code:54745-4546
Mailing Address - Country:US
Mailing Address - Phone:715-204-9221
Mailing Address - Fax:
Practice Address - Street 1:550 RIVER RD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3212
Practice Address - Country:US
Practice Address - Phone:541-743-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-21
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist