1578843686 NPI number — ELIZABETH PENELOPE JACOBO LCSW

Table of content: ELIZABETH PENELOPE JACOBO LCSW (NPI 1578843686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578843686 NPI number — ELIZABETH PENELOPE JACOBO LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBO
Provider First Name:
ELIZABETH
Provider Middle Name:
PENELOPE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARCIA
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
PENELOPE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578843686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 WIND RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92019-4132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-203-9870
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8530 LA MESA BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-798-7413
Provider Business Practice Location Address Fax Number:
833-419-0181
Provider Enumeration Date:
08/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  80614 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1578843686 . This is a "N/A" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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