Provider Demographics
NPI:1275950032
Name:JACOBSON, JERILYNN
Entity Type:Individual
Prefix:
First Name:JERILYNN
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JERILYNN
Other - Middle Name:
Other - Last Name:GIESKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4545 CLAWSON TANK DR STE D
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2583
Mailing Address - Country:US
Mailing Address - Phone:810-626-5191
Mailing Address - Fax:
Practice Address - Street 1:4545 CLAWSON TANK DR STE D
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2583
Practice Address - Country:US
Practice Address - Phone:810-626-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010915091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509139660OtherBCBS
MI034530OtherVALUE OPTIONS
MI034530OtherVALUE OPTIONS