Basic Information
| Provider Information | |||||||||
| NPI: | 1730819384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBS-NICHOLLS | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 NE COURTNEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Practice Location | |||||||||
| Address1: | 63311 JAMISON ST | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977038288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2022 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.