Provider Demographics
NPI:1487103701
Name:HENRY, JACOB (LPC-MHSP-S, LPCC-S)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:LPC-MHSP-S, LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 COBBLE ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7912
Mailing Address - Country:US
Mailing Address - Phone:502-396-9125
Mailing Address - Fax:
Practice Address - Street 1:5217 MARYLAND WAY STE 307
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-1056
Practice Address - Country:US
Practice Address - Phone:615-882-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224036101YM0800X
KY279920101YM0800X
TN3595101YM0800X, 101YP2500X
OK12106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health