Provider Demographics
NPI:1912046640
Name:JACOB, LUKOSE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:LUKOSE
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7765 S CR 251
Mailing Address - Street 2:RMC-DEPT. OF CORRECTIONS,
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32504
Mailing Address - Country:US
Mailing Address - Phone:386-496-6000
Mailing Address - Fax:
Practice Address - Street 1:7765 S COUNTY ROAD 231
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-5721
Practice Address - Country:US
Practice Address - Phone:386-496-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLXXXXXX1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical