Provider Demographics
NPI:1164561593
Name:JACOBS, THOMAS (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 PARK GLEN RD
Mailing Address - Street 2:#150
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4871
Mailing Address - Country:US
Mailing Address - Phone:612-872-9446
Mailing Address - Fax:
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:#150
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:612-872-9446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0122106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist