Provider Demographics
NPI:1073692695
Name:JACOBSON, GARY MICHAEL (LCSW, CASAC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MICHAEL
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:ROSENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12472-9734
Mailing Address - Country:US
Mailing Address - Phone:845-658-3606
Mailing Address - Fax:845-658-3606
Practice Address - Street 1:7 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1137
Practice Address - Country:US
Practice Address - Phone:845-256-2220
Practice Address - Fax:845-255-9211
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR034699-11041C0700X
MEME2664691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4491OtherCASAC
MEME266469OtherMAINE CLINICAL SOCIAL WOR
NYR034699-1OtherLCSW
NYN77502Medicare ID - Type Unspecified