Provider Demographics
NPI:1083372106
Name:JACOBSON, ALEXIS NICOLE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1519
Mailing Address - Country:US
Mailing Address - Phone:218-220-7845
Mailing Address - Fax:
Practice Address - Street 1:723 3RD AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1519
Practice Address - Country:US
Practice Address - Phone:218-220-7845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30219101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health