Provider Demographics
NPI:1386671485
Name:JACOBS, JULIE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:A
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 MIDLAND CT
Mailing Address - Street 2:SUITE #102
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2336
Mailing Address - Country:US
Mailing Address - Phone:608-756-9090
Mailing Address - Fax:608-756-2920
Practice Address - Street 1:519 MIDLAND CT
Practice Address - Street 2:SUITE #102
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2336
Practice Address - Country:US
Practice Address - Phone:608-756-9090
Practice Address - Fax:608-756-2920
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI882-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39046200Medicaid