Provider Demographics
NPI:1033413315
Name:JACOBSON, JERROLD (BCBA CAP LMHC)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:BCBA CAP LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7422 SW HORSE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-8894
Mailing Address - Country:US
Mailing Address - Phone:863-494-9251
Mailing Address - Fax:863-494-9251
Practice Address - Street 1:7422 SW HORSE CREEK RD
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8894
Practice Address - Country:US
Practice Address - Phone:863-494-9251
Practice Address - Fax:863-494-9251
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2389101YA0400X
FLMH 4420101YM0800X
FL1-01-0707103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL676127598Medicaid
FL676127596Medicaid