| NPI | 1164598892 |
|---|---|
| Former Name | JAKE IBSEN |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| Enumeration Date | 2006-11-27 |
| Last Update Date | 2012-03-28 |