Provider Demographics
NPI:1831705920
Name:MERRITT, JACOB LANE (MA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LANE
Last Name:MERRITT
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 AMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4426
Mailing Address - Country:US
Mailing Address - Phone:214-418-4510
Mailing Address - Fax:
Practice Address - Street 1:412 SW HWY 101
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-2772
Practice Address - Country:US
Practice Address - Phone:541-557-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health