Provider Demographics
NPI:1881385466
Name:JACOBS, VANESSA (MHC-LP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 WITTENBERG RD
Mailing Address - Street 2:
Mailing Address - City:BEARSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12409-5631
Mailing Address - Country:US
Mailing Address - Phone:917-930-7058
Mailing Address - Fax:
Practice Address - Street 1:404 ZENA RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2626
Practice Address - Country:US
Practice Address - Phone:845-315-7908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P121305-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health