Provider Demographics
NPI:1316515117
Name:HANSEN, JACOB (PCLC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 N 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2814
Mailing Address - Country:US
Mailing Address - Phone:406-396-6067
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGGINS AVE STE 222
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4443
Practice Address - Country:US
Practice Address - Phone:406-351-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-62388101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor