Basic Information
| Provider Information | |||||||||
| NPI: | 1245984186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | ELYSSA | ||||||||
| MiddleName: | E | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5412 LINDLEY AVE UNIT 207 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913161918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182674020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18646 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913561486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2022 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 92344 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.