Basic Information
| Provider Information | |||||||||
| NPI: | 1184810244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3628 STOCKDALE HWY | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933092153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613221021 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3628 STOCKDALE HWY | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933092153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613221021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | AMFT112693 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106H00000X | AMFT112693 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.