Provider Demographics
NPI:1295824696
Name:JACOBSEN, MARY LOU (MSSW, LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:MSSW, LICSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW, LICSW
Mailing Address - Street 1:610 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4704
Practice Address - Country:US
Practice Address - Phone:507-451-2630
Practice Address - Fax:507-455-8133
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN82061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4G504WAOtherBLUE CROSS BLUE SHIELD
MN118039OtherUCARE
MN62-20365OtherUNITED BEHAVIORAL HEALTH
MN074027600Medicaid
MNHP20016OtherHEALTH PARTNERS