Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003296195 |
---|---|
Provider Name | Dustin Jacobsen |
First Address | Kentfield, CA 94904-1418 |
Second Address | Kentfield, CA 94904-1418 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2015 |
Last Update Date | 03/06/2015 |