Provider Demographics
NPI:1952581183
Name:DONNELLY, JACOB (LCSW)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DONNELLY
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 1:3021 TELEGRAPH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2072
Mailing Address - Country:US
Mailing Address - Phone:510-982-6836
Mailing Address - Fax:
Practice Address - Street 1:1060 HOWARD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2820
Practice Address - Country:US
Practice Address - Phone:415-252-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CAASW 275631041C0700X
CA639001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker