Provider Demographics
NPI:1003969064
Name:JACOBS, DONNA WITHEE (LICSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:WITHEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1139
Mailing Address - Country:US
Mailing Address - Phone:413-353-0027
Mailing Address - Fax:413-353-0027
Practice Address - Street 1:260 PARK ST
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1139
Practice Address - Country:US
Practice Address - Phone:413-353-0027
Practice Address - Fax:413-353-0027
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0188141041C0700X
MA1171901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0050800OtherGHI - GROUP HEALTH INC.
NYP407545OtherOXFORD
NY144811OtherVALUE OPTIONS