Provider Demographics
NPI:1356629414
Name:JACOBSEN, MARY JAMIA (LCSW, LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JAMIA
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N POST RD STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4213
Mailing Address - Country:US
Mailing Address - Phone:317-282-3088
Mailing Address - Fax:317-295-2555
Practice Address - Street 1:1515 N POST RD STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4213
Practice Address - Country:US
Practice Address - Phone:317-282-3088
Practice Address - Fax:317-295-2555
Is Sole Proprietor?:No
Enumeration Date:2011-07-23
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35000016A106H00000X
IN34002287A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist