Individual
MRS. BRENDA LAVONNE JACOB
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MS, CCDC III, LAT
Contact information
Practice address
113 S GILLETTE AVE, GILLETTE, WY 82716-3740
(307) 685-6982
(307) 685-8054
Mailing address
701 FAIRWAY DR, GILLETTE, WY 82718-7605
(307) 689-0666
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
99111065
SD
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
LAT-270
WY
Other
Enumeration date
06/23/2009
Last updated
06/23/2009
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