Provider Demographics
NPI:1174055198
Name:SLOUKA, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:SLOUKA
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 1:264 LANDIS AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2627
Mailing Address - Country:US
Mailing Address - Phone:619-977-6851
Mailing Address - Fax:619-278-0885
Practice Address - Street 1:264 LANDIS AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2627
Practice Address - Country:US
Practice Address - Phone:619-977-6851
Practice Address - Fax:619-278-0885
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-25405103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst