Provider Demographics
NPI:1619918430
Name:JACOBS, WILLIAM (LPCC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC
Mailing Address - Street 1:8608 CLARIDGE PL NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-6209
Mailing Address - Country:US
Mailing Address - Phone:505-379-0810
Mailing Address - Fax:520-203-0179
Practice Address - Street 1:1127 ALAMEDA BLVD NW STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-1240
Practice Address - Country:US
Practice Address - Phone:505-379-0810
Practice Address - Fax:520-201-0179
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0065602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4232782Medicaid