Provider Demographics
NPI:1073826913
Name:JACOBY, SCOTT MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:MICHAEL
Last Name:JACOBY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 WINSLOW AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1340
Mailing Address - Country:US
Mailing Address - Phone:612-669-3430
Mailing Address - Fax:
Practice Address - Street 1:2110 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-3196
Practice Address - Country:US
Practice Address - Phone:952-353-5931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5269103TB0200X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy