Provider Demographics
NPI:1295863801
Name:JACOBSON, MICHELE (LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1726 SE 3RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316
Mailing Address - Country:US
Mailing Address - Phone:954-522-4749
Mailing Address - Fax:
Practice Address - Street 1:420 SE 18TH STREET
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-522-4749
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL768055400Medicaid