Provider Demographics
NPI:1114159811
Name:JACOBS, MARIANN (L-CSWR)
Entity Type:Individual
Prefix:MS
First Name:MARIANN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:L-CSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 S BERGEN PL
Mailing Address - Street 2:2T
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3505
Mailing Address - Country:US
Mailing Address - Phone:516-379-3112
Mailing Address - Fax:516-379-3112
Practice Address - Street 1:76 S BERGEN PL
Practice Address - Street 2:2T
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3505
Practice Address - Country:US
Practice Address - Phone:516-379-3112
Practice Address - Fax:516-379-3112
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YA0400X
NYR036854-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)