Provider Demographics
NPI:1447024930
Name:VILLA, JACOB I
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:I
Last Name:VILLA
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 1:29122 CITATION AVE
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-9714
Mailing Address - Country:US
Mailing Address - Phone:909-568-9818
Mailing Address - Fax:
Practice Address - Street 1:31946 MISSION TRL STE B
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4539
Practice Address - Country:US
Practice Address - Phone:951-245-7663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist