Provider Demographics
NPI:1982921417
Name:SPENCER, JACOB FELIX (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:FELIX
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 JOHNSTONVILLE ROAD
Mailing Address - Street 2:#270503
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130
Mailing Address - Country:US
Mailing Address - Phone:530-310-7818
Mailing Address - Fax:
Practice Address - Street 1:27000 N HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-8900
Practice Address - Country:US
Practice Address - Phone:530-310-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
CAPSY27901103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health