Provider Demographics
NPI:1881178325
Name:JACOB WHITE PH.D., PLLC
Entity type:Organization
Organization Name:JACOB WHITE PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:231-935-8900
Mailing Address - Street 1:3537 W. FRONT STREET
Mailing Address - Street 2:SUITE F
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-935-8900
Mailing Address - Fax:231-935-8901
Practice Address - Street 1:3537 W. FRONT STREET
Practice Address - Street 2:SUITE F
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-8900
Practice Address - Fax:231-935-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty