Provider Demographics
NPI:1023381670
Name:JACOBSON, JOSHUA MICHAEL
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
Last Name:JACOBSON
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 1:463B ERNEST BILES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-2229
Mailing Address - Country:US
Mailing Address - Phone:770-504-5645
Mailing Address - Fax:770-504-5646
Practice Address - Street 1:463B ERNEST BILES DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-2229
Practice Address - Country:US
Practice Address - Phone:770-504-5645
Practice Address - Fax:770-504-5646
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional