Provider Demographics
NPI:1316403678
Name:JACOBSON, AMANDA COLLEY (LPC, CAADC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:COLLEY
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 HOLMDENE BLVD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3730
Mailing Address - Country:US
Mailing Address - Phone:248-935-5135
Mailing Address - Fax:
Practice Address - Street 1:800 MONROE AVE NW STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1448
Practice Address - Country:US
Practice Address - Phone:248-935-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
MI6401019189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)