Provider Demographics
NPI:1053944439
Name:JACKSON-WOLF, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JACKSON-WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 SWEETBRIER LN
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-3416
Mailing Address - Country:US
Mailing Address - Phone:443-804-8822
Mailing Address - Fax:
Practice Address - Street 1:1206 YORK RD STE 202
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6217
Practice Address - Country:US
Practice Address - Phone:443-718-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional