Provider Demographics
NPI:1922856533
Name:CORONA, JACOB (LMFT ASSOCIATE)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CORONA
Suffix:
Gender:M
Credentials:LMFT ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 UNIVERSITY DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2130
Mailing Address - Country:US
Mailing Address - Phone:817-304-7549
Mailing Address - Fax:
Practice Address - Street 1:451 UNIVERSITY DR STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2130
Practice Address - Country:US
Practice Address - Phone:817-304-7549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205230106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist