Provider Demographics
NPI:1003917907
Name:JACOBSON, MONICA I (PHD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:I
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 LINCOLN STREET
Mailing Address - Street 2:
Mailing Address - City:KEWAUNEE
Mailing Address - State:WI
Mailing Address - Zip Code:54216
Mailing Address - Country:US
Mailing Address - Phone:920-388-7030
Mailing Address - Fax:920-388-7044
Practice Address - Street 1:810 LINCOLN STREET
Practice Address - Street 2:
Practice Address - City:KEWAUNEE
Practice Address - State:WI
Practice Address - Zip Code:54216
Practice Address - Country:US
Practice Address - Phone:920-388-7030
Practice Address - Fax:920-388-7044
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1595057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39089700Medicaid