Provider Demographics
NPI:1831540210
Name:GOTWALS, JACOB KULP (MA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:KULP
Last Name:GOTWALS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 N WILD DAISY PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85750-3139
Mailing Address - Country:US
Mailing Address - Phone:505-336-0088
Mailing Address - Fax:
Practice Address - Street 1:3355 N WILD DAISY PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85750-3139
Practice Address - Country:US
Practice Address - Phone:505-336-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016856101YM0800X, 101YP2500X
NMCCMH0206221101YP2500X, 101YM0800X
AZLPC-21792101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional