Provider Demographics
NPI:1275933160
Name:JACOBSON LONG, SHEILA MICHELLE (CSW)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:MICHELLE
Last Name:JACOBSON LONG
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 W 4700 S
Mailing Address - Street 2:G-1
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-2156
Mailing Address - Country:US
Mailing Address - Phone:801-613-7490
Mailing Address - Fax:
Practice Address - Street 1:2880 W 4700 S
Practice Address - Street 2:G-1
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2156
Practice Address - Country:US
Practice Address - Phone:801-613-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT9816324-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor