Provider Demographics
NPI:1366453110
Name:JACOBSON, HOWARD A (PH D)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:A
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 VERDAE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4032
Mailing Address - Country:US
Mailing Address - Phone:864-546-7315
Mailing Address - Fax:
Practice Address - Street 1:1025 VERDAE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4032
Practice Address - Country:US
Practice Address - Phone:864-546-7315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1110103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2009378OtherBCBST
TN3682434Medicaid
TN4064458OtherAETNA
SC3682434Medicare PIN