Provider Demographics
NPI:1144593237
Name:JACOBSEN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:JACOBSEN
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92531-0549
Mailing Address - Country:US
Mailing Address - Phone:951-216-7300
Mailing Address - Fax:951-216-7333
Practice Address - Street 1:3757 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2508
Practice Address - Country:US
Practice Address - Phone:951-216-7300
Practice Address - Fax:951-216-7333
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)