Provider Demographics
NPI:1942047923
Name:AUSTIN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:AUSTIN
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 1:2524 S WASHINGTON ST STE 5
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6764
Mailing Address - Country:US
Mailing Address - Phone:701-520-7211
Mailing Address - Fax:
Practice Address - Street 1:2524 S WASHINGTON ST STE 5
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6764
Practice Address - Country:US
Practice Address - Phone:701-520-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional