Provider Demographics
NPI:1073680377
Name:JACOBSON, COURTNEY M (LCSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:M
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 S FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-4316
Mailing Address - Country:US
Mailing Address - Phone:417-887-1977
Mailing Address - Fax:
Practice Address - Street 1:440 S MARKET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2026
Practice Address - Country:US
Practice Address - Phone:417-496-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024437104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker